Provider Demographics
NPI:1760657969
Name:KIMBERLY MCRAE, INC.
Entity Type:Organization
Organization Name:KIMBERLY MCRAE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SPEECH-LANGUAGE PATHOLOGI
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:MCRAE
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:224-522-5315
Mailing Address - Street 1:1868 W BROADSMORE LN
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-8151
Mailing Address - Country:US
Mailing Address - Phone:224-522-5315
Mailing Address - Fax:847-740-9019
Practice Address - Street 1:1868 W BROADSMORE LN
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-8151
Practice Address - Country:US
Practice Address - Phone:224-522-5315
Practice Address - Fax:847-740-9019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146007781261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04932537OtherBLUECROSS BLUESHIELD