Provider Demographics
NPI:1730625336
Name:GOLLES, KIMBERLEE MOUNTAIN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:MOUNTAIN
Last Name:GOLLES
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 HEARST AVE
Mailing Address - Street 2:#104
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1284
Mailing Address - Country:US
Mailing Address - Phone:530-355-3861
Mailing Address - Fax:
Practice Address - Street 1:1425 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5318
Practice Address - Country:US
Practice Address - Phone:925-295-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22788235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist