Provider Demographics
NPI:1497112122
Name:HARRISON, KIMBERLY (MACCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3452 W COLETTE CT
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-2309
Mailing Address - Country:US
Mailing Address - Phone:901-413-8719
Mailing Address - Fax:
Practice Address - Street 1:101 FALLS RD
Practice Address - Street 2:SUITE 403
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-2612
Practice Address - Country:US
Practice Address - Phone:414-559-0050
Practice Address - Fax:262-421-8681
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4216235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist