Provider Demographics
NPI:1407060767
Name:SHEAD, KIMBERLY LAVEARNE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LAVEARNE
Last Name:SHEAD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1665 PETE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7328
Mailing Address - Country:US
Mailing Address - Phone:662-334-3579
Mailing Address - Fax:
Practice Address - Street 1:1665 PETE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7328
Practice Address - Country:US
Practice Address - Phone:662-334-3579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2002235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist