Provider Demographics
NPI:1710390828
Name:MIKKELSON, KIMBERLY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:3055 LEBANON PIKE STE 2100
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37214-2246
Practice Address - Country:US
Practice Address - Phone:615-314-3351
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4915235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist