Provider Demographics
NPI:1528556131
Name:MARCUM, KIMBERLY (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:MARCUM
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:LUENSMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:8523 US HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670-5895
Mailing Address - Country:US
Mailing Address - Phone:903-918-2071
Mailing Address - Fax:
Practice Address - Street 1:921 SHILOH RD # C120T
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1431
Practice Address - Country:US
Practice Address - Phone:903-939-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-29
Last Update Date:2018-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.013637235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist