Provider Demographics
NPI:1598751737
Name:DANIEL, KIMBERLY ROSE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ROSE
Last Name:DANIEL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2356
Mailing Address - Country:US
Mailing Address - Phone:715-526-7266
Mailing Address - Fax:715-526-7294
Practice Address - Street 1:116 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2356
Practice Address - Country:US
Practice Address - Phone:715-526-7266
Practice Address - Fax:715-526-7294
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2030-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42804000Medicaid