MEDICARE: MRS. KIMBERLY MARIE DOUGLAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SLPL5190	AZ

General Provider Information

NPI Number	:	1609941962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY MARIE DOUGLAS

Provider Business Mailing Address
First Line	:	1625 WEST GERONIMO STREET
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85224
Country	:	US
Telephone Number	:	480-782-0572
Fax Number	:

Provider Business Practice Location Address
First Line	:	1625 W GERONIMO ST
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85224-5616
Country	:	US
Telephone Number	:	480-782-0572
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	07/08/2007

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