Provider Demographics
NPI:1821358847
Name:PENDERGRASS, KIMBERLY NICOLE (MA CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 WESTSHIRE PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-4663
Mailing Address - Country:US
Mailing Address - Phone:803-229-5162
Mailing Address - Fax:
Practice Address - Street 1:112 WESTSHIRE PL
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-4663
Practice Address - Country:US
Practice Address - Phone:803-229-5162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5316235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist