1205917267 NPI number — KIMBERLY DAWN PALMER MA, CCC-A

Table of content: KIMBERLY DAWN PALMER MA, CCC-A (NPI 1205917267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205917267 NPI number — KIMBERLY DAWN PALMER MA, CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PALMER
Provider First Name:
KIMBERLY
Provider Middle Name:
DAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, CCC-A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLAIR
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, CCC-A
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1205917267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 N SAINT JOSEPH AVE
Provider Second Line Business Mailing Address:
C 1
Provider Business Mailing Address City Name:
NILES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49120-2263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-683-0800
Provider Business Mailing Address Fax Number:
269-683-7638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 JOHN ST
Provider Second Line Business Practice Location Address:
SUITE M-273
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49007-5341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-381-0180
Provider Business Practice Location Address Fax Number:
269-381-7347
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237600000X , with the licence number:  35-01-003406 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2996538 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010689294050 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4439159 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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