Provider Demographics
NPI:1063546141
Name:EGBERTS, KIMBERLY ANN (MSCCC-SLP)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:EGBERTS
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 ROCK RIDGE RUN
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND CENTER
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3730
Mailing Address - Country:US
Mailing Address - Phone:207-829-4763
Mailing Address - Fax:207-829-4763
Practice Address - Street 1:500 ROUTE 1
Practice Address - Street 2:SUITE #23
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-4711
Practice Address - Country:US
Practice Address - Phone:207-653-8263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP518235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME100278Medicare UPIN