Basic Information
| Provider Information | |||||||||
| NPI: | 1700046091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PLACE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DEANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITESIDE | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | DEANN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S., CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1349 EMPIRE CENTRAL DR | ||||||||
| Address2: | SUITE 516 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752474066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4693648600 | ||||||||
| FaxNumber: | 4693648595 | ||||||||
| Practice Location | |||||||||
| Address1: | 1349 EMPIRE CENTRAL DR | ||||||||
| Address2: | SUITE 516 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752474066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4693648600 | ||||||||
| FaxNumber: | 4693648595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2008 | ||||||||
| LastUpdateDate: | 05/07/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 24595 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.