Provider Demographics
NPI:1770094559
Name:CONDIE, KIMBERLY JEANNE (MS, CCC-SLP, CNT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JEANNE
Last Name:CONDIE
Suffix:
Gender:F
Credentials:MS, CCC-SLP, CNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 75TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-3425
Mailing Address - Country:US
Mailing Address - Phone:302-593-1369
Mailing Address - Fax:
Practice Address - Street 1:400 E 75TH ST APT 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-3425
Practice Address - Country:US
Practice Address - Phone:302-593-1369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCSLP000841235Z00000X
DEO1-0001177235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist