Provider Demographics
NPI:1659572188
Name:WISKOW, KIMBERLY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WISKOW
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 1:4029 SUMMERHILL LN
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-0906
Mailing Address - Country:US
Mailing Address - Phone:817-637-7546
Mailing Address - Fax:
Practice Address - Street 1:855 DAVIS BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-8244
Practice Address - Country:US
Practice Address - Phone:817-310-3457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101452235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist