Provider Demographics
NPI:1366440422
Name:MIREK, KIMBERLY MARIE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:MIREK
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 1:4736 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53219-4716
Mailing Address - Country:US
Mailing Address - Phone:414-306-1410
Mailing Address - Fax:
Practice Address - Street 1:4214 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-4142
Practice Address - Country:US
Practice Address - Phone:262-515-2434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146007081235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist