Provider Demographics
NPI:1770976144
Name:WILSON-LEWIS, KIMBERLY RENEE (PHD/CCC-SLP)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:RENEE
Last Name:WILSON-LEWIS
Suffix:
Gender:F
Credentials:PHD/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 BRECKENRIDGE TRCE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2988
Mailing Address - Country:US
Mailing Address - Phone:615-669-6418
Mailing Address - Fax:
Practice Address - Street 1:462 BRECKENRIDGE TRCE
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-2988
Practice Address - Country:US
Practice Address - Phone:615-669-6418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006884235Z00000X
TN6628235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ048423Medicaid