Provider Demographics
NPI:1235550773
Name:ANDERSON, KIMBERLY DIANE (MS-CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DIANE
Last Name:ANDERSON
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 1:7005 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-8730
Mailing Address - Country:US
Mailing Address - Phone:817-433-9742
Mailing Address - Fax:
Practice Address - Street 1:6601 HARRIS PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6108
Practice Address - Country:US
Practice Address - Phone:817-433-9742
Practice Address - Fax:817-433-9699
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103642235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist