Provider Demographics
NPI:1588983878
Name:MRYGLOT, KIMBERLY SMITH (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SMITH
Last Name:MRYGLOT
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 1:10459 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-3264
Mailing Address - Country:US
Mailing Address - Phone:607-936-6347
Mailing Address - Fax:
Practice Address - Street 1:10459 NORTH RD
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-3264
Practice Address - Country:US
Practice Address - Phone:607-936-6347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005165-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist