Provider Demographics
NPI:1659656577
Name:MCCLUSKEY, KIMBERLY M
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:MCCLUSKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:FITZGERALD (GETMAN)
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:726 N CECIL ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:MO
Mailing Address - Zip Code:63555-1900
Mailing Address - Country:US
Mailing Address - Phone:660-988-4614
Mailing Address - Fax:
Practice Address - Street 1:726 N CECIL ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:MO
Practice Address - Zip Code:63555-1900
Practice Address - Country:US
Practice Address - Phone:660-988-4614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010031395235Z00000X
IA002275235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO110921152529004Medicaid