Provider Demographics
NPI:1164903647
Name:FONGEMIE, KIRK MAURICE
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:MAURICE
Last Name:FONGEMIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3629
Mailing Address - Country:US
Mailing Address - Phone:207-797-0600
Mailing Address - Fax:
Practice Address - Street 1:1133 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3629
Practice Address - Country:US
Practice Address - Phone:207-797-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP2539235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist