Provider Demographics
NPI:1750155586
Name:PARKS, KEMBER LEE
Entity type:Individual
Prefix:
First Name:KEMBER
Middle Name:LEE
Last Name:PARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEMBER
Other - Middle Name:LEE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:2115 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8007
Mailing Address - Country:US
Mailing Address - Phone:970-254-4872
Mailing Address - Fax:
Practice Address - Street 1:2115 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8007
Practice Address - Country:US
Practice Address - Phone:970-254-4872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14072378235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist