Provider Demographics
NPI:1043994197
Name:KLINE, KIMBERLY LAUREN (LISAC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LAUREN
Last Name:KLINE
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6262 E BROADWAY RD STE 110
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6101
Mailing Address - Country:US
Mailing Address - Phone:480-210-5570
Mailing Address - Fax:
Practice Address - Street 1:6262 E BROADWAY RD STE 110
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6101
Practice Address - Country:US
Practice Address - Phone:480-210-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-155279101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)