Provider Demographics
NPI:1326558859
Name:GONZALES, KIMBERLY RAE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RAE
Last Name:GONZALES
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 1:1731 CORAL RD
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1604
Mailing Address - Country:US
Mailing Address - Phone:516-776-2885
Mailing Address - Fax:
Practice Address - Street 1:40 OAK DR
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4649
Practice Address - Country:US
Practice Address - Phone:516-776-2885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027113-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist