Provider Demographics
NPI:1013160134
Name:ABUSHAKRA, KIMBERLY A (MS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:ABUSHAKRA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 LAKE TREE DR SW
Mailing Address - Street 2:
Mailing Address - City:OCEAN ISLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28469-4762
Mailing Address - Country:US
Mailing Address - Phone:843-280-3755
Mailing Address - Fax:
Practice Address - Street 1:128 HIGHWAY 17 S
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-3118
Practice Address - Country:US
Practice Address - Phone:843-280-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4303235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist