Basic Information
| Provider Information | |||||||||
| NPI: | 1497986756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEMESMIN | ||||||||
| FirstName: | KIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3265 BIDDLE RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414146736 | ||||||||
| FaxNumber: | 5417874011 | ||||||||
| Practice Location | |||||||||
| Address1: | 3265 BIDDLE RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136531149 | ||||||||
| FaxNumber: | 8136546644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2009 | ||||||||
| LastUpdateDate: | 05/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 105211 | TX | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 235Z00000X | SA11923 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 007228900 | 05 | FL | MEDICAID | 014323100 | 05 | FL | MEDICAID |