Provider Demographics
NPI:1356457600
Name:RODRIGUEZ, KIMBERLYN (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLYN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16187 W GIBSON LN
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-3449
Mailing Address - Country:US
Mailing Address - Phone:623-363-1999
Mailing Address - Fax:
Practice Address - Street 1:45 S 3RD AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-2264
Practice Address - Country:US
Practice Address - Phone:623-772-5190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0608235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ872251Medicare UPIN