Basic Information
| Provider Information | |||||||||
| NPI: | 1740614940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN BUREN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CIFUNI | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS. CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 105 MORTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIDLEY PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190782409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105211331 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 105 MORTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIDLEY PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190782409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105211331 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2013 | ||||||||
| LastUpdateDate: | 08/25/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SL011242 | PA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 022463 | NY | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.