Basic Information
| Provider Information | |||||||||
| NPI: | 1730562802 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIDEMAN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | WATTS | ||||||||
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| Credential: | M.S., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 DUTCHESS DR | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275134239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196384239 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1829 E FRANKLIN ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275145863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199683456 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2015 | ||||||||
| LastUpdateDate: | 07/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 7734 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.