MEDICARE: KIMBERLY RAE GONZALES CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	027113-1	NY

General Provider Information

NPI Number	:	1326558859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY RAE GONZALES CCC-SLP

Provider Business Mailing Address
First Line	:	1731 CORAL RD
Second Line	:
City	:	EAST MEADOW
State	:	NY
Zip	:	11554-1604
Country	:	US
Telephone Number	:	516-776-2885
Fax Number	:

Provider Business Practice Location Address
First Line	:	40 OAK DR
Second Line	:
City	:	SYOSSET
State	:	NY
Zip	:	11791-4649
Country	:	US
Telephone Number	:	516-776-2885
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2017
Last Update Date	:	10/11/2017

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Directions to “ KIMBERLY RAE GONZALES CCC-SLP” Practice Location

Language	Start Address	Practice Location

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