Basic Information
| Provider Information | |||||||||
| NPI: | 1437318789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEEMKUIL | ||||||||
| FirstName: | CORA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.S. CFY-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 404 REVERE ST | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232464600 | ||||||||
| FaxNumber: | 4232463311 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 REVERE ST | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232464600 | ||||||||
| FaxNumber: | 4232463311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2008 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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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 | 235Z00000X | TN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 0446506 | 05 | TN | MEDICAID |