Provider Demographics
NPI:1225570252
Name:WALLER, KIM (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004-50 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:OAKVILLE
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L6J7W1
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1004-50 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:OAKVILLE
Practice Address - State:ONTARIO
Practice Address - Zip Code:L6J7W1
Practice Address - Country:CA
Practice Address - Phone:905-808-3436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist