Provider Demographics
NPI:1902383946
Name:HAVERKAMP, KIMBERLY K
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
Last Name:HAVERKAMP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15955 NEW HALLS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-1227
Mailing Address - Country:US
Mailing Address - Phone:314-953-4991
Mailing Address - Fax:
Practice Address - Street 1:15955 NEW HALLS FERRY RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-1227
Practice Address - Country:US
Practice Address - Phone:314-953-4991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO465926400Medicaid