Basic Information
| Provider Information | |||||||||
| NPI: | 1962963868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARRS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CA SLPA LICENSE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1818 MOORE BLVD APT 202 | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956187684 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 803 RUSSELL BLVD | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956163426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303918670 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2019 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
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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 | 2355S0801X | 5432 | CA | Y | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
No ID Information.