Provider Demographics
NPI:1871221754
Name:STEPHENS, KIM JEAN (MHS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:JEAN
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:MHS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WESTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1771
Mailing Address - Country:US
Mailing Address - Phone:573-999-1813
Mailing Address - Fax:
Practice Address - Street 1:1700 W ASHLEY RD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-2162
Practice Address - Country:US
Practice Address - Phone:660-882-2744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022031132235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist