Provider Demographics
NPI:1659436624
Name:LAURIE, KIMBERLY ANN (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:LAURIE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:BURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:8522 W FALLING STAR ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6367
Mailing Address - Country:US
Mailing Address - Phone:208-362-4049
Mailing Address - Fax:
Practice Address - Street 1:890 N COLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8638
Practice Address - Country:US
Practice Address - Phone:208-323-8888
Practice Address - Fax:208-323-8889
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP1419235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12003294OtherASHA
IDSP748OtherBLUE CROSS INSURANCE
ID000010148695OtherREGENCE BLUESHIELD OF ID