Basic Information
| Provider Information | |||||||||
| NPI: | 1376686881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIMMEY | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | LESLIE | ||||||||
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| Credential: | MS,CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2840 NE 19TH ST | ||||||||
| Address2: | |||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330623109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547858052 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2840 NE 19TH ST | ||||||||
| Address2: | |||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330623109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549439589 | ||||||||
| FaxNumber: | 9549434115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 12/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA5518 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 222Q00000X | SA 5518 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 890371900 | 05 | FL | MEDICAID |