Healthcare Provider Details

I. General information

NPI: 1871229906
Provider Name (Legal Business Name): KIMBERLY STEWART
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13579 DONEGAL ST
MORENO VALLEY CA
92555-5628
US

IV. Provider business mailing address

13579 DONEGAL ST
MORENO VALLEY CA
92555-5628
US

V. Phone/Fax

Practice location:
  • Phone: 951-315-1974
  • Fax:
Mailing address:
  • Phone: 951-315-1974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22178
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number7346
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: