Provider Demographics
NPI:1902802424
Name:KIZIMINSKI, KELLY J (SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:KIZIMINSKI
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-5203
Mailing Address - Country:US
Mailing Address - Phone:304-231-3820
Mailing Address - Fax:304-243-0440
Practice Address - Street 1:2203 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5203
Practice Address - Country:US
Practice Address - Phone:304-231-3820
Practice Address - Fax:304-243-0440
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7402187000Medicaid