Provider Demographics
NPI:1043845894
Name:BUFFINGTON-LATOUR, KIMBERLY ANNE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:BUFFINGTON-LATOUR
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MRS
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:BUFFINGTON-LATOUR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:4456 RADNOR RD
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-9151
Mailing Address - Country:US
Mailing Address - Phone:952-454-8987
Mailing Address - Fax:
Practice Address - Street 1:4456 RADNOR RD
Practice Address - Street 2:
Practice Address - City:MOUND
Practice Address - State:MN
Practice Address - Zip Code:55364-9151
Practice Address - Country:US
Practice Address - Phone:952-454-8987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10357235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist