Provider Demographics
NPI:1730481664
Name:BUSHNELL, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BUSHNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 N SCHOOL AVE
Mailing Address - Street 2:
Mailing Address - City:HARTVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65667
Mailing Address - Country:US
Mailing Address - Phone:417-741-7676
Mailing Address - Fax:417-741-6668
Practice Address - Street 1:175 N SCHOOL AVE
Practice Address - Street 2:
Practice Address - City:HARTVILLE
Practice Address - State:MO
Practice Address - Zip Code:65667
Practice Address - Country:US
Practice Address - Phone:417-741-7676
Practice Address - Fax:417-741-6668
Is Sole Proprietor?:No
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113084235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist