Provider Demographics
NPI:1114291499
Name:DESOTO, KIMBERLY D (MS, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:D
Last Name:DESOTO
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 ASHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-8717
Mailing Address - Country:US
Mailing Address - Phone:817-822-7057
Mailing Address - Fax:
Practice Address - Street 1:728 ASHWOOD LN
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-8717
Practice Address - Country:US
Practice Address - Phone:817-822-7057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-03
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12221101YA0400X, 101YM0800X, 101YP2500X
OK5870101YP2500X
FLMH 12221101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health