Provider Demographics
NPI:1902497340
Name:THE PRACTICAL CLINICIAN PLLC
Entity Type:Organization
Organization Name:THE PRACTICAL CLINICIAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:WILSON-LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD , CCC-SLP
Authorized Official - Phone:678-667-4650
Mailing Address - Street 1:462 BRECKENRIDGE TRCE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2988
Mailing Address - Country:US
Mailing Address - Phone:678-667-4650
Mailing Address - Fax:
Practice Address - Street 1:462 BRECKENRIDGE TRCE
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-2988
Practice Address - Country:US
Practice Address - Phone:678-667-4650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty