Provider Demographics
NPI:1871004085
Name:SCANLON, KIMBERLY ROBERTSON (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROBERTSON
Last Name:SCANLON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LYNN
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:284 BLANTON LN
Mailing Address - Street 2:
Mailing Address - City:COTTAGEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29435-3108
Mailing Address - Country:US
Mailing Address - Phone:843-909-0748
Mailing Address - Fax:
Practice Address - Street 1:284 BLANTON LN
Practice Address - Street 2:
Practice Address - City:COTTAGEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29435-3108
Practice Address - Country:US
Practice Address - Phone:843-909-0748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-14
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY168249235Z00000X
SC6936235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist