Provider Demographics
NPI:1780910182
Name:BENTON, KIMBERLY (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:BENTON
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 1:201 S NORTHPARK LN
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-8426
Mailing Address - Country:US
Mailing Address - Phone:417-623-4313
Mailing Address - Fax:417-621-0129
Practice Address - Street 1:2202 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-5328
Practice Address - Country:US
Practice Address - Phone:918-964-7025
Practice Address - Fax:918-964-7024
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009015713235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist