Provider Demographics
NPI:1730562802
Name:WIDEMAN, KIMBERLY WATTS (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:WATTS
Last Name:WIDEMAN
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 1:213 DUTCHESS DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-4239
Mailing Address - Country:US
Mailing Address - Phone:919-638-4239
Mailing Address - Fax:
Practice Address - Street 1:1829 E FRANKLIN ST STE 600
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-5863
Practice Address - Country:US
Practice Address - Phone:919-968-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7734235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist