Basic Information
| Provider Information | |||||||||
| NPI: | 1740625474 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | TETRO | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | LORRAINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3575 QUAKERBRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086191271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096312800 | ||||||||
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| Address1: | 3575 QUAKERBRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086191271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096312800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2013 | ||||||||
| LastUpdateDate: | 05/08/2013 | ||||||||
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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 | 41YS00702200 | NJ | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 41YS00702200 | 01 | NJ | SPEECH LANGUAGE PATHOLOGIST | OTHER |