Provider Demographics
NPI:1922022920
Name:THOMAS, KIMPER CANNON (SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIMPER
Middle Name:CANNON
Last Name:THOMAS
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 1:754 IDEAL WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5627
Mailing Address - Country:US
Mailing Address - Phone:704-343-0202
Mailing Address - Fax:
Practice Address - Street 1:2017 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5313
Practice Address - Country:US
Practice Address - Phone:704-609-8255
Practice Address - Fax:704-371-7385
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8370235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0639Medicaid