Provider Demographics
NPI:1548405111
Name:WARD, KIM T (MA, CCC/SLP)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:T
Last Name:WARD
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:T
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC/SLP
Mailing Address - Street 1:3928 N CALLE GRANDE
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-0990
Mailing Address - Country:US
Mailing Address - Phone:575-393-0755
Mailing Address - Fax:575-393-0249
Practice Address - Street 1:315 E CLINTON ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-8238
Practice Address - Country:US
Practice Address - Phone:575-393-0755
Practice Address - Fax:575-393-0249
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4134235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ3326Medicaid