Provider Demographics
NPI:1649295692
Name:SCOTT, KIMBERLY RAE (PHD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RAE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 CREEK CABIN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-5835
Mailing Address - Country:US
Mailing Address - Phone:210-679-5262
Mailing Address - Fax:
Practice Address - Street 1:859 MDW/MCSRA
Practice Address - Street 2:2200 BERQUIST DR, STE 1
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-5300
Practice Address - Country:US
Practice Address - Phone:210-292-5420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14207235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist