Provider Demographics
NPI:1447634969
Name:GRANT, KIMBERLY (MA,CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GRANT
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 1:9102 N LILLEY RD
Mailing Address - Street 2:#249
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4644
Mailing Address - Country:US
Mailing Address - Phone:734-634-4681
Mailing Address - Fax:
Practice Address - Street 1:9102 N LILLEY RD
Practice Address - Street 2:#249
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4644
Practice Address - Country:US
Practice Address - Phone:734-634-4681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101004282235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist