Provider Demographics
NPI:1922834852
Name:GORDON, KIMBERLY KRISTEN PERRY (M ED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KRISTEN PERRY
Last Name:GORDON
Suffix:
Gender:F
Credentials:M ED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 DOGWOOD HILLS RD
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-5305
Mailing Address - Country:US
Mailing Address - Phone:229-942-1304
Mailing Address - Fax:
Practice Address - Street 1:173 DOGWOOD HILLS RD
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-5305
Practice Address - Country:US
Practice Address - Phone:229-942-1304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009722235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist