Healthcare Provider Details

I. General information

NPI: 1639142409
Provider Name (Legal Business Name): KIMBERLEE A. WUELLNER MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 CARPENTER AVE
MOORESVILLE NC
28115-2512
US

IV. Provider business mailing address

510 CARPENTER AVE
MOORESVILLE NC
28115-2512
US

V. Phone/Fax

Practice location:
  • Phone: 704-528-0808
  • Fax:
Mailing address:
  • Phone: 704-528-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3611
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: