Provider Demographics
NPI:1487204772
Name:GIBBONS, KENDELL NICOLE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:KENDELL
Middle Name:NICOLE
Last Name:GIBBONS
Suffix:
Gender:
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13435 SPRING GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-5547
Mailing Address - Country:US
Mailing Address - Phone:142-909-0270
Mailing Address - Fax:
Practice Address - Street 1:3000 PEGASUS PARK DR STE 1100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-6203
Practice Address - Country:US
Practice Address - Phone:469-621-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114915235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114915Medicaid