Provider Demographics
NPI:1598148355
Name:VESTAL, KIMBERLY (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:VESTAL
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 NE VIEW PL
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-2123
Mailing Address - Country:US
Mailing Address - Phone:971-998-3824
Mailing Address - Fax:
Practice Address - Street 1:3860 NE VIEW PL
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2123
Practice Address - Country:US
Practice Address - Phone:971-998-3824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13594235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist