Basic Information
| Provider Information | |||||||||
| NPI: | 1982075818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN GRAHAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D., CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAHAM | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S., CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 40277 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366400277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514459378 | ||||||||
| FaxNumber: | 2514459377 | ||||||||
| Practice Location | |||||||||
| Address1: | 5721 USA DR N | ||||||||
| Address2: | HAHN 119 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366880002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514459365 | ||||||||
| FaxNumber: | 2514459376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2015 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2202005953 | VA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 3863 | AL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.