Provider Demographics
NPI:1912458092
Name:SMITH, KIMBERLY GRACE (MS, CCC-SLP, TSSLD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:GRACE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, CCC-SLP, TSSLD
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:GRACE
Other - Last Name:HAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP, TSSLD
Mailing Address - Street 1:220 LINCOLN PL
Mailing Address - Street 2:APT 2F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3761
Mailing Address - Country:US
Mailing Address - Phone:631-943-2033
Mailing Address - Fax:
Practice Address - Street 1:220 LINCOLN PL
Practice Address - Street 2:APT 2F
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-3761
Practice Address - Country:US
Practice Address - Phone:631-241-5612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024548-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist