Provider Demographics
NPI:1518436278
Name:KINCANNON, SEMETRAH ALIMA (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:SEMETRAH
Middle Name:ALIMA
Last Name:KINCANNON
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12722 SILVER SPUR WAY
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-7437
Mailing Address - Country:US
Mailing Address - Phone:760-694-3240
Mailing Address - Fax:855-719-2558
Practice Address - Street 1:15409 ANACAPA RD STE 409A
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2463
Practice Address - Country:US
Practice Address - Phone:760-278-1484
Practice Address - Fax:855-719-2558
Is Sole Proprietor?:No
Enumeration Date:2018-11-24
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP28180235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist