Provider Demographics
NPI:1164795704
Name:WILSON, KIMBERLY RENEE (CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:RENEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S KESWICK AVE
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-4509
Mailing Address - Country:US
Mailing Address - Phone:267-312-1443
Mailing Address - Fax:
Practice Address - Street 1:107 S KESWICK AVE
Practice Address - Street 2:
Practice Address - City:GLENSIDE
Practice Address - State:PA
Practice Address - Zip Code:19038-4509
Practice Address - Country:US
Practice Address - Phone:267-312-1443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist