Provider Demographics
NPI:1043656861
Name:SCARDINA, KIM (LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:SCARDINA
Suffix:
Gender:F
Credentials:LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 N SHELTON LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-4530
Mailing Address - Country:US
Mailing Address - Phone:309-264-5769
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0002
Practice Address - Country:US
Practice Address - Phone:309-655-3958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008553101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional