Provider Demographics
NPI:1679759740
Name:BURGESS, KIMBERLY LAINE (MS, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LAINE
Last Name:BURGESS
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 1:6800 132ND PL SE UNIT E302
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98059-9111
Mailing Address - Country:US
Mailing Address - Phone:817-995-4275
Mailing Address - Fax:
Practice Address - Street 1:4560 SE INTERNATIONAL WAY
Practice Address - Street 2:STE 100
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-4628
Practice Address - Country:US
Practice Address - Phone:971-206-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102554235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist