Healthcare Provider Details

I. General information

NPI: 1922283654
Provider Name (Legal Business Name): KIMBERLY ANN OHLSSON M.ED., C.C.C., S.L.P
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 12/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 IMPERIAL WAY
BOGART GA
30622-1794
US

IV. Provider business mailing address

249 IMPERIAL WAY
BOGART GA
30622-1794
US

V. Phone/Fax

Practice location:
  • Phone: 706-254-3255
  • Fax:
Mailing address:
  • Phone: 706-254-3255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP003774
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: