Provider Demographics
NPI:1821378266
Name:KIMBROUGH, TAYLOR (SLP)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:BUSSIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10733 REVERE RD
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-1903
Mailing Address - Country:US
Mailing Address - Phone:708-837-8869
Mailing Address - Fax:708-694-7006
Practice Address - Street 1:10733 REVERE RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-1903
Practice Address - Country:US
Practice Address - Phone:708-837-8869
Practice Address - Fax:708-694-7006
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146010537235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932114OtherBCBS