Provider Demographics
NPI:1710542279
Name:MOURLAS, KIMBERLY A
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:MOURLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:MOURLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:53 BUNTINGS MILL CT
Mailing Address - Street 2:
Mailing Address - City:SELBYVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19975-3626
Mailing Address - Country:US
Mailing Address - Phone:410-726-7055
Mailing Address - Fax:
Practice Address - Street 1:100 BUCKINGHAM RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1499
Practice Address - Country:US
Practice Address - Phone:410-726-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03840235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist