Provider Demographics
NPI:1881952984
Name:HARRELL, KIMMERLY K (SLP)
Entity type:Individual
Prefix:
First Name:KIMMERLY
Middle Name:K
Last Name:HARRELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4709 TUGALO TRL
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-5879
Mailing Address - Country:US
Mailing Address - Phone:352-282-1367
Mailing Address - Fax:
Practice Address - Street 1:4709 TUGALO TRL
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-5879
Practice Address - Country:US
Practice Address - Phone:352-282-1367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008206235Z00000X
FLSA12108235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist