Provider Demographics
NPI:1891916318
Name:STAVLO, KIMBERLY J (SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:STAVLO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DEER LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59722
Mailing Address - Country:US
Mailing Address - Phone:406-846-3448
Mailing Address - Fax:406-846-2298
Practice Address - Street 1:310 MAIN STREET
Practice Address - Street 2:
Practice Address - City:DEER LODGE
Practice Address - State:MT
Practice Address - Zip Code:59722
Practice Address - Country:US
Practice Address - Phone:406-846-3448
Practice Address - Fax:406-846-2298
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0052494Medicaid