Provider Demographics
NPI:1851546980
Name:CLARK, KIMBERLINE GEANELLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLINE
Middle Name:GEANELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
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Other - First Name:
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Mailing Address - Street 1:2424 MILL CREEK CT
Mailing Address - Street 2:SUITE1
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-8300
Mailing Address - Country:US
Mailing Address - Phone:850-656-1699
Mailing Address - Fax:850-656-9200
Practice Address - Street 1:2424 MILL CREEK CT
Practice Address - Street 2:SUITE1
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8300
Practice Address - Country:US
Practice Address - Phone:850-656-1600
Practice Address - Fax:850-656-9200
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLSA 8792235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist