Provider Demographics
NPI:1164780706
Name:ANDREW, KIMBERLY JO (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JO
Last Name:ANDREW
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3873
Mailing Address - Country:US
Mailing Address - Phone:208-241-7496
Mailing Address - Fax:
Practice Address - Street 1:421 E OAK ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4601
Practice Address - Country:US
Practice Address - Phone:208-241-7496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-4159101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional