Provider Demographics
NPI:1982997045
Name:DEVER, KIMBERLY TRACI (CCC/SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:TRACI
Last Name:DEVER
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 BEVILLE RD STE J
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5765
Mailing Address - Country:US
Mailing Address - Phone:386-252-7837
Mailing Address - Fax:386-252-0021
Practice Address - Street 1:1104 BEVILLE RD STE J
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5765
Practice Address - Country:US
Practice Address - Phone:386-252-7837
Practice Address - Fax:386-252-0021
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6115235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist