Provider Demographics
NPI:1851647168
Name:FOWLER, KYMRY HART (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KYMRY
Middle Name:HART
Last Name:FOWLER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20122 SANTA ANA AVE APT 7C
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1360
Mailing Address - Country:US
Mailing Address - Phone:949-374-4868
Mailing Address - Fax:
Practice Address - Street 1:140 S FLOWER ST STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3467
Practice Address - Country:US
Practice Address - Phone:714-683-5876
Practice Address - Fax:888-420-6257
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP17425235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP17425OtherCALIFORNIA SPEECH LANGUAGE PATHOLOGIST LICENSE