Provider Demographics
NPI:1023509734
Name:SMITH, KIMBERLY TERSILLA (AUD)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:TERSILLA
Last Name:SMITH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:TERSILLA
Other - Last Name:LEDDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:1111 EXPOSITION BLVD BLDG 700
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4314
Mailing Address - Country:US
Mailing Address - Phone:916-736-3399
Mailing Address - Fax:916-233-4171
Practice Address - Street 1:10200 TRINITY PKWY STE 201
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-7288
Practice Address - Country:US
Practice Address - Phone:209-952-0483
Practice Address - Fax:209-478-5785
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU3301231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist