Provider Demographics
NPI:1154585123
Name:HIDDLESON, KIMBERLY JO (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:HIDDLESON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 DOVE ST
Mailing Address - Street 2:SUITE 280
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-3023
Mailing Address - Country:US
Mailing Address - Phone:949-567-0025
Mailing Address - Fax:949-567-0026
Practice Address - Street 1:901 DOVE ST
Practice Address - Street 2:SUITE 280
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-3023
Practice Address - Country:US
Practice Address - Phone:949-567-0025
Practice Address - Fax:949-567-0026
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP8075235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist