Provider Demographics
NPI:1356010763
Name:MCKILLOP, KIMBERLY JOY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOY
Last Name:MCKILLOP
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JOY
Other - Last Name:STOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9501 NW 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-6225
Mailing Address - Country:US
Mailing Address - Phone:208-585-7336
Mailing Address - Fax:360-604-6722
Practice Address - Street 1:13400 NE 9TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:360-604-6720
Practice Address - Fax:360-604-6722
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61168762235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist