Provider Demographics
NPI:1811307382
Name:GREENE, KIMBERLY (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GREENE
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 1:1012 SOUTH THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WA
Mailing Address - Zip Code:99328
Mailing Address - Country:US
Mailing Address - Phone:509-382-2531
Mailing Address - Fax:509-382-9359
Practice Address - Street 1:1012 SOUTH THIRD STREET
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:WA
Practice Address - Zip Code:99328
Practice Address - Country:US
Practice Address - Phone:509-382-2531
Practice Address - Fax:509-382-9359
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 00003864235Z00000X
WALL00003864235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist