Provider Demographics
NPI:1780997635
Name:NELSON, KIMBERLY ANN (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:NELSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 BRYANT STRATTON WAY
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6013
Mailing Address - Country:US
Mailing Address - Phone:716-631-5777
Mailing Address - Fax:
Practice Address - Street 1:4444 BRYANT STRATTON WAY
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6013
Practice Address - Country:US
Practice Address - Phone:716-631-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019278235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist