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
State | License ID | Taxonomies |
---|---|---|
FL | SA5518 | 235Z00000X |
FL | SA 5518 | 222Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | |
No | 222Q00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 890371900 | Medicaid |