Provider Demographics
NPI:1790948081
Name:KITTELSON, KIMBERLY MICHELLE (SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:KITTELSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 W FREEPORT ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-2144
Mailing Address - Country:US
Mailing Address - Phone:918-688-6575
Mailing Address - Fax:
Practice Address - Street 1:3800 W FREEPORT ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-2144
Practice Address - Country:US
Practice Address - Phone:918-688-6575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2490235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist