Provider Demographics
NPI:1003617507
Name:KIMBALL, MICHAELA ROSE
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:ROSE
Last Name:KIMBALL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3066 PORTALS AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-9380
Mailing Address - Country:US
Mailing Address - Phone:559-281-1095
Mailing Address - Fax:
Practice Address - Street 1:3066 PORTALS AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619-9380
Practice Address - Country:US
Practice Address - Phone:559-281-1095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74502355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant