Provider Demographics
NPI:1376686881
Name:KIMMEY, GINA LESLIE (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:LESLIE
Last Name:KIMMEY
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 1:2840 NE 19TH ST
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-3109
Mailing Address - Country:US
Mailing Address - Phone:954-785-8052
Mailing Address - Fax:
Practice Address - Street 1:2840 NE 19TH ST
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-3109
Practice Address - Country:US
Practice Address - Phone:954-943-9589
Practice Address - Fax:954-943-4115
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5518235Z00000X
FLSA 5518222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890371900Medicaid