Provider Demographics
NPI:1124429790
Name:DUNHAM, KIMBERLY BRIDGET (MS CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:BRIDGET
Last Name:DUNHAM
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 TERRACE WAY
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1329
Mailing Address - Country:US
Mailing Address - Phone:315-487-3429
Mailing Address - Fax:
Practice Address - Street 1:5525 IKE DIXON RD
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-8682
Practice Address - Country:US
Practice Address - Phone:315-672-3159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-14
Last Update Date:2014-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021766-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist