Provider Demographics
NPI:1225142839
Name:WALLACE, KIMBERLY D (SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-6805
Mailing Address - Country:US
Mailing Address - Phone:618-779-8255
Mailing Address - Fax:618-288-5494
Practice Address - Street 1:1 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-6805
Practice Address - Country:US
Practice Address - Phone:618-779-8255
Practice Address - Fax:618-288-5494
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist