Basic Information
| Provider Information | |||||||||
| NPI: | 1376507046 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLLISTER | ||||||||
| FirstName: | KIMBERLEY | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | AUD,CCC/A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29321 ORCHARD LAKE RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483342968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485538270 | ||||||||
| FaxNumber: | 2485538185 | ||||||||
| Practice Location | |||||||||
| Address1: | 27483 DEQUINDRE AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480715711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485410100 | ||||||||
| FaxNumber: | 2483993960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 804845416 | 05 | MI | MEDICAID | 904826232 | 05 | MI | MEDICAID |