Provider Demographics
NPI:1366004491
Name:PARK, KIMBERLY (CF-SLP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-1926
Mailing Address - Country:US
Mailing Address - Phone:660-349-5086
Mailing Address - Fax:
Practice Address - Street 1:401 MATT WALLER DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MO
Practice Address - Zip Code:64085-2270
Practice Address - Country:US
Practice Address - Phone:816-776-3059
Practice Address - Fax:816-776-2608
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty