Provider Demographics
NPI:1902274335
Name:MCLEOD, KIM (MA CCC SLP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:MCLEOD
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:L
Other - Last Name:MOLLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:820 SILVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4950
Mailing Address - Country:US
Mailing Address - Phone:321-377-2595
Mailing Address - Fax:
Practice Address - Street 1:820 SILVERWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4950
Practice Address - Country:US
Practice Address - Phone:321-377-2595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13407235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist