Provider Demographics
NPI:1144841131
Name:GILLIS, KIMBERLY ANN (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:GILLIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 DEER MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:CHICHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03258-6502
Mailing Address - Country:US
Mailing Address - Phone:603-892-4271
Mailing Address - Fax:
Practice Address - Street 1:300 BELANGER DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NH
Practice Address - Zip Code:03275-3258
Practice Address - Country:US
Practice Address - Phone:603-485-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01106622235Z00000X
NH1405235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01106622OtherAMERICAN SPEECH-LANGUAGE HEARING ASSOCIATION (ASHA)
NH1405OtherNEW HAMPSHIRE OFFICE OF LICENSED ALLIED HEALTH PROFESSIONALS