Provider Demographics
NPI:1669956330
Name:KIM, AMANDA KRISTEN (MS , CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:KRISTEN
Last Name:KIM
Suffix:
Gender:F
Credentials:MS , CCC-SLP
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Mailing Address - Street 1:3570 EXECUTIVE DR STE 208
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-8712
Mailing Address - Country:US
Mailing Address - Phone:330-595-9173
Mailing Address - Fax:330-595-1525
Practice Address - Street 1:3570 EXECUTIVE DR STE 208
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685-8712
Practice Address - Country:US
Practice Address - Phone:330-595-9173
Practice Address - Fax:330-595-1525
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.11095235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist