Provider Demographics
NPI:1376507046
Name:HOLLISTER, KIMBERLEY SUE (AUD,CCC/A)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:SUE
Last Name:HOLLISTER
Suffix:
Gender:F
Credentials:AUD,CCC/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29321 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2968
Mailing Address - Country:US
Mailing Address - Phone:248-553-8270
Mailing Address - Fax:248-553-8185
Practice Address - Street 1:27483 DEQUINDRE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-5711
Practice Address - Country:US
Practice Address - Phone:248-541-0100
Practice Address - Fax:248-399-3960
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI804845416Medicaid
MI904826232Medicaid
MI904826232Medicaid