Provider Demographics
NPI:1154650307
Name:REARDON, KIMBERLY ANN (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:REARDON
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:BUSSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 OREGON AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7461
Mailing Address - Country:US
Mailing Address - Phone:253-861-5165
Mailing Address - Fax:
Practice Address - Street 1:15 OREGON AVE STE 111
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7461
Practice Address - Country:US
Practice Address - Phone:253-861-5165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-17
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00046380101YM0800X
WALH60398032101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health