Provider Demographics
NPI:1982233797
Name:GAMMON, KIMBERLY MARIE (MS-CCC SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:GAMMON
Suffix:
Gender:F
Credentials:MS-CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6125 ROSWELL RD UNIT 442
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-3936
Mailing Address - Country:US
Mailing Address - Phone:404-908-2095
Mailing Address - Fax:
Practice Address - Street 1:545 OLD NORCROSS RD STE 200
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3390
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010982235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist