Provider Demographics
NPI:1962520957
Name:LACROSS, KIMBERLY ANN (MA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:LACROSS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 MICHIGAN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4911
Mailing Address - Country:US
Mailing Address - Phone:616-393-2190
Mailing Address - Fax:
Practice Address - Street 1:577 MICHIGAN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4911
Practice Address - Country:US
Practice Address - Phone:616-393-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000322231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M26220Medicare ID - Type UnspecifiedAUDIOLOGIST