Provider Demographics
NPI:1619231818
Name:BLUNT, KIMBERLY LATORIA
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LATORIA
Last Name:BLUNT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LATORIA
Other - Last Name:LASTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2409 FORMAX DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-9327
Mailing Address - Country:US
Mailing Address - Phone:850-341-3022
Mailing Address - Fax:
Practice Address - Street 1:2409 FORMAX DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9327
Practice Address - Country:US
Practice Address - Phone:850-341-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11671235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist