Healthcare Provider Details

I. General information

NPI: 1376497479
Provider Name (Legal Business Name): KIMBERLEY IVORY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM IVORY

II. Dates (important events)

Enumeration Date: 02/25/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

368 JUANA AVE
SAN LEANDRO CA
94577-4811
US

IV. Provider business mailing address

150 4TH ST APT 640
OAKLAND CA
94607-2161
US

V. Phone/Fax

Practice location:
  • Phone: 877-367-9772
  • Fax:
Mailing address:
  • Phone: 281-889-5927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number35993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: