Provider Demographics
NPI:1093935264
Name:DECOOK, KIMBERLY M
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:M
Last Name:DECOOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800-85TH ST. CT. W.
Mailing Address - Street 2:
Mailing Address - City:TAYLOR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:61284
Mailing Address - Country:US
Mailing Address - Phone:309-737-5077
Mailing Address - Fax:
Practice Address - Street 1:9800 85TH STREET CT W
Practice Address - Street 2:
Practice Address - City:TAYLOR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:61284-9261
Practice Address - Country:US
Practice Address - Phone:309-737-5077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist