Provider Demographics
NPI:1851437990
Name:PETERS, KIMBERLY ANN (PHD, CCC-A/SLP)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:PETERS
Suffix:
Gender:F
Credentials:PHD, CCC-A/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 HIGH ST
Mailing Address - Street 2:MS 9171
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5946
Mailing Address - Country:US
Mailing Address - Phone:360-650-3206
Mailing Address - Fax:360-650-2843
Practice Address - Street 1:516 HIGH ST
Practice Address - Street 2:MS 9171
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5946
Practice Address - Country:US
Practice Address - Phone:360-650-3206
Practice Address - Fax:360-650-2843
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00003523231H00000X
WALL60042669235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAQMXPR0069859Medicare ID - Type UnspecifiedMOLINA PROVIDER ID
WA7129018Medicare ID - Type UnspecifiedDSHS ID NUMBER