| Doctor Name: | KIMBERLY WALLIS-RUCKLOS |
| NPI Number: | 1548446420 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MA CCC SLP |
| License Number: | SLP-1374 |
| Business Practice Address: | 6855 W Fairview Ave Ste. 120 Boise, ID - 837048502 |
| Business Phone Number: | 2083238888 |
| Business Fax Number: | 2083238889 |
| Mailing Address: | 6855 W Fairview Ave, Ste. 120 BOISE |
| State: | ID |
| Postal Code: | 837048502 |
| Phone Number: | 2083238888 |
| Fax Number: | 2083238889 |
| NPI Enumeration Date: | 01/10/2008 |
| NPI Last Update Date: | 01/10/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | SLP-1374 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |