Provider Demographics
NPI:1629110408
Name:KIDD, KIMBERLEY WILSON (LL)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:WILSON
Last Name:KIDD
Suffix:
Gender:F
Credentials:LL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:2700 152ND AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-5543
Practice Address - Country:US
Practice Address - Phone:425-883-5693
Practice Address - Fax:425-883-5929
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00001796235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8410821Medicaid