Provider Demographics
NPI:1760538524
Name:PEREZ, KIMBERLY KAY (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KAY
Last Name:PEREZ
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 S MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-4235
Mailing Address - Country:US
Mailing Address - Phone:575-317-6709
Mailing Address - Fax:
Practice Address - Street 1:1700 S MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-4235
Practice Address - Country:US
Practice Address - Phone:575-317-6709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM801235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM74201Medicaid