Provider Demographics
NPI:1740587138
Name:CARTER, KIMBERLY DALE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DALE
Last Name:CARTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 BAXTER AVE
Mailing Address - Street 2:APT 4
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-2046
Mailing Address - Country:US
Mailing Address - Phone:270-256-7792
Mailing Address - Fax:
Practice Address - Street 1:9810 BLUEGRASS PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1906
Practice Address - Country:US
Practice Address - Phone:502-584-9781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY11-011235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist