Provider Demographics
NPI:1730486424
Name:ELLIOTT, KIM MICHELE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:MICHELE
Last Name:ELLIOTT
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 1:1645 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-4514
Mailing Address - Country:US
Mailing Address - Phone:503-289-5584
Mailing Address - Fax:
Practice Address - Street 1:1645 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4514
Practice Address - Country:US
Practice Address - Phone:503-708-5720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13057235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist