Provider Demographics
NPI:1356686026
Name:ENNIS, KIMBERLY A (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:ENNIS
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 1:1351 WEST PINE AVE.
Mailing Address - Street 2:MERIDIAN CARE AND REHABILITATION CENTER
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-888-7246
Mailing Address - Fax:
Practice Address - Street 1:1351 WEST PINE AVE.
Practice Address - Street 2:MERIDIAN CARE AND REHABILITATION CENTER
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-888-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1152235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist