Provider Demographics
NPI:1023518834
Name:ULRICH, KIMBERLY MARIE HAGAN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE HAGAN
Last Name:ULRICH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:HAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:4757 HABERSHAM RDG SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-5602
Mailing Address - Country:US
Mailing Address - Phone:770-366-5678
Mailing Address - Fax:
Practice Address - Street 1:4757 HABERSHAM RDG SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-5602
Practice Address - Country:US
Practice Address - Phone:770-366-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008462235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist