Provider Demographics
NPI:1831504687
Name:KIMBLE, SHAYNE (MCD CF-SLP)
Entity type:Individual
Prefix:
First Name:SHAYNE
Middle Name:
Last Name:KIMBLE
Suffix:
Gender:M
Credentials:MCD CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5545 DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3159
Mailing Address - Country:US
Mailing Address - Phone:318-359-8634
Mailing Address - Fax:
Practice Address - Street 1:3347 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3842
Practice Address - Country:US
Practice Address - Phone:318-466-6111
Practice Address - Fax:318-466-6113
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA#7138235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist