Provider Demographics
NPI:1861523839
Name:SIEGEL, KIM (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:SIEGEL
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 1:13623 WOODRIVER DR
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:MO
Mailing Address - Zip Code:64060-8920
Mailing Address - Country:US
Mailing Address - Phone:816-516-7297
Mailing Address - Fax:
Practice Address - Street 1:13623 WOODRIVER DR
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:MO
Practice Address - Zip Code:64060-8920
Practice Address - Country:US
Practice Address - Phone:816-516-7297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01580235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO01580OtherMISSOURI STATE BOARD OF REGISTRATION FOR THE HEALING ARTS