Provider Demographics
NPI:1114329372
Name:MITCHELL, KIMBERLEY PAIGE HERMAN (MA-CCC/SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:PAIGE HERMAN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MA-CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 OLDE DEER TRL
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-6388
Mailing Address - Country:US
Mailing Address - Phone:616-786-0072
Mailing Address - Fax:
Practice Address - Street 1:439 OLDE DEER TRL
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-6388
Practice Address - Country:US
Practice Address - Phone:616-786-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101004382235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist