Provider Demographics
NPI:1508036989
Name:TULLOCK, KIMBERLY R (MA - CCC-A)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:TULLOCK
Suffix:
Gender:F
Credentials:MA - CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 E. SHEMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444
Mailing Address - Country:US
Mailing Address - Phone:231-737-0527
Mailing Address - Fax:231-733-4093
Practice Address - Street 1:1155 E. SHEMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444
Practice Address - Country:US
Practice Address - Phone:231-737-0527
Practice Address - Fax:231-733-4093
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000110231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist