Provider Demographics
NPI:1669578019
Name:MOUNTAIN, KIMBERLY NILES (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NILES
Last Name:MOUNTAIN
Suffix:
Gender:F
Credentials:MS 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:PO BOX 482
Mailing Address - Street 2:
Mailing Address - City:ROLLINSFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03869-0482
Mailing Address - Country:US
Mailing Address - Phone:603-834-4082
Mailing Address - Fax:
Practice Address - Street 1:3 FRONT ST
Practice Address - Street 2:SUITE 404
Practice Address - City:ROLLINSFORD
Practice Address - State:NH
Practice Address - Zip Code:03869-7001
Practice Address - Country:US
Practice Address - Phone:603-834-4082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1283235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME281180099Medicaid