Provider Demographics
NPI:1760629562
Name:PREWITT, KIMBERLY SUE (MA SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:PREWITT
Suffix:
Gender:F
Credentials:MA SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13830-3391
Mailing Address - Country:US
Mailing Address - Phone:607-843-6213
Mailing Address - Fax:
Practice Address - Street 1:18 BROAD ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2106
Practice Address - Country:US
Practice Address - Phone:607-798-7117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018405-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist