=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144841131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY ANN GILLIS MS, CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2020
-----------------------------------------------------
Last Update Date | 05/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 BELANGER DR
-----------------------------------------------------
City | PEMBROKE
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03275-3258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-485-9000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 DEER MEADOW RD
-----------------------------------------------------
City | CHICHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03258-6502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-892-4271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 01106622
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 1405
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------