Provider Demographics
NPI:1710440698
Name:CARLSON, KIMBERLY ROBIN (SPEECH LANGUAGE PATH)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROBIN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 S ATLANTIC AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2172
Mailing Address - Country:US
Mailing Address - Phone:910-584-7381
Mailing Address - Fax:
Practice Address - Street 1:3355 S ATLANTIC AVE APT 4
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-2172
Practice Address - Country:US
Practice Address - Phone:910-584-7381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13571235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist