=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689739914
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY PETTIS M.S.CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 BELLE TERRE RD
-----------------------------------------------------
City | PORT JEFFERSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11777-1928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-474-6263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 ROBIN DR
-----------------------------------------------------
City | HAUPPAUGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11788-1104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-656-8180
-----------------------------------------------------
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 | 012235-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------