Provider Demographics
NPI:1376537332
Name:KIESTER, MARILYN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:KIESTER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:
Other - Last Name:GOURLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:16420 WOOLWINE RD.
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270
Mailing Address - Country:US
Mailing Address - Phone:704-953-9653
Mailing Address - Fax:704-587-9531
Practice Address - Street 1:6924 NEEDHAM DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-2837
Practice Address - Country:US
Practice Address - Phone:704-607-0014
Practice Address - Fax:704-442-8724
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6638235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412331Medicaid
NC1391AOtherNC BCBS