Provider Demographics
NPI:1144743105
Name:GRAY, KIMBER (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBER
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:BROOMFIELD
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 BRANCH VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-0833
Mailing Address - Country:US
Mailing Address - Phone:678-313-8464
Mailing Address - Fax:
Practice Address - Street 1:3385 TRICKUM RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4234
Practice Address - Country:US
Practice Address - Phone:678-909-4930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007226235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist