Provider Demographics
NPI:1053771758
Name:WADE, KIMBERLY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7808 S URBANA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8111
Mailing Address - Country:US
Mailing Address - Phone:918-441-8554
Mailing Address - Fax:
Practice Address - Street 1:6846 S CANTON AVE STE 120
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3412
Practice Address - Country:US
Practice Address - Phone:918-441-8554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4431235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist