Provider Demographics
NPI:1114446978
Name:MILDER, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MILDER
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 1:401 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:LENA
Mailing Address - State:IL
Mailing Address - Zip Code:61048-8610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 FREMONT ST
Practice Address - Street 2:
Practice Address - City:LENA
Practice Address - State:IL
Practice Address - Zip Code:61048-8610
Practice Address - Country:US
Practice Address - Phone:815-369-3108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146006279235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist