Provider Demographics
NPI:1295176311
Name:STOLLY, KIMBERLY BEACH (CCC SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BEACH
Last Name:STOLLY
Suffix:
Gender:F
Credentials:CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5159 SHOSHONE TRL
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-4117
Mailing Address - Country:US
Mailing Address - Phone:303-520-1592
Mailing Address - Fax:
Practice Address - Street 1:804 S MUMAUGH RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-3569
Practice Address - Country:US
Practice Address - Phone:419-225-9040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7460235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist