Provider Demographics
NPI:1659703239
Name:ENOKSEN, KIM LOUISE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:LOUISE
Last Name:ENOKSEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-4510
Mailing Address - Country:US
Mailing Address - Phone:516-799-5433
Mailing Address - Fax:
Practice Address - Street 1:103 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-4510
Practice Address - Country:US
Practice Address - Phone:516-799-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009565-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist