Provider Demographics
NPI:1295046670
Name:GUTIERREZ, KIMBERLY RICHARDSON (MA, CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:RICHARDSON
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1371 E 4000 N
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5149
Mailing Address - Country:US
Mailing Address - Phone:208-201-5621
Mailing Address - Fax:
Practice Address - Street 1:73 N MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455
Practice Address - Country:US
Practice Address - Phone:208-201-5621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1143235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist