Provider Demographics
NPI:1437869781
Name:COUNCIL, KIMBERLY (SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:COUNCIL
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 1:107 WILD ROSE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-8470
Mailing Address - Country:US
Mailing Address - Phone:706-540-9051
Mailing Address - Fax:
Practice Address - Street 1:190 SOUTHPARK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4209
Practice Address - Country:US
Practice Address - Phone:904-824-1478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10077235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist