Provider Demographics
NPI:1942512652
Name:TICE, KIMBERLY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:TICE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:CRESCENTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:2350 NW 33RD ST
Mailing Address - Street 2:APT 802
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-6460
Mailing Address - Country:US
Mailing Address - Phone:516-279-0234
Mailing Address - Fax:
Practice Address - Street 1:2685 EXECUTIVE PARK DR
Practice Address - Street 2:SUITE 5
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3651
Practice Address - Country:US
Practice Address - Phone:954-372-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-10
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020090-1235Z00000X
FLSA10982235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003659000Medicaid