MEDICARE: KIMBERLEY GLISE, M.S. 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	NV SP-797	NV

General Provider Information

NPI Number	:	1407900814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIMBERLEY GLISE, M.S. CCC-SLP

Provider Business Mailing Address
First Line	:	2373 VIEWCREST RD
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89014-3156
Country	:	US
Telephone Number	:	702-461-1353
Fax Number	:	702-549-2608

Provider Business Practice Location Address
First Line	:	4600 E SUNSET RD
Second Line	:	SUITE 179
City	:	HENDERSON
State	:	NV
Zip	:	89014-2202
Country	:	US
Telephone Number	:	702-461-5661
Fax Number	:	702-549-2608

Authorized Official
Title or Position	:	DIRECTOR SLP
Name	:	MRS. KIMBERLEY ANNE GLISE
Credential	:	M.S. CCC-SLP
Telephone Number	:	702-461-1353

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	08/22/2020

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