Provider Demographics
NPI:1811044068
Name:STEWART, KIMBERLY ANNE (CCC-SLP)
Entity Type:Individual
Prefix:PROF
First Name:KIMBERLY
Middle Name:ANNE
Last Name:STEWART
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3266 RANGE CT
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-8494
Mailing Address - Country:US
Mailing Address - Phone:985-237-4944
Mailing Address - Fax:985-718-1878
Practice Address - Street 1:132 SOUTH 6TH STREET
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454
Practice Address - Country:US
Practice Address - Phone:985-969-0517
Practice Address - Fax:985-718-1878
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3432235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CB89Medicare ID - Type UnspecifiedMEDICARE GROUP#