1740816305 NPI number — KIMBERLY JO MCKENZIE M.A., CCC-SLP

Table of content: KIMBERLY JO MCKENZIE M.A., CCC-SLP (NPI 1740816305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740816305 NPI number — KIMBERLY JO MCKENZIE M.A., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKENZIE
Provider First Name:
KIMBERLY
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740816305
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1402 COMMERCE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25701-1611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-412-4533
Provider Business Mailing Address Fax Number:
303-398-7043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1402 COMMERCE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25701-1611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-412-4533
Provider Business Practice Location Address Fax Number:
303-398-7043
Provider Enumeration Date:
03/16/2020

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: 235Z00000X , with the licence number:  SLP-2058 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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