Healthcare Provider Details

I. General information

NPI: 1689027112
Provider Name (Legal Business Name): KIMBERLY MIEBACH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 11/10/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 TOWER DR SUITE 400
MIDDLETOWN NY
10941-2056
US

IV. Provider business mailing address

156 RT 15 NORTH
LAFFAYETTE NJ
07848
US

V. Phone/Fax

Practice location:
  • Phone: 845-692-4391
  • Fax:
Mailing address:
  • Phone: 973-862-6377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number41YS00961300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: