Provider Demographics
NPI:1790205946
Name:EDMONSON, KIMBERLI PAIGE (SLP-ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KIMBERLI
Middle Name:PAIGE
Last Name:EDMONSON
Suffix:
Gender:F
Credentials:SLP-ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4933 LEMON GROVE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-1549
Mailing Address - Country:US
Mailing Address - Phone:817-454-0857
Mailing Address - Fax:
Practice Address - Street 1:8836 LARCH ST
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:TX
Practice Address - Zip Code:76135-4616
Practice Address - Country:US
Practice Address - Phone:817-454-0857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX395552355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant