Provider Demographics
NPI:1235129446
Name:COURNOYER-BAUM, KIMBERLY J (EDS)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:J
Last Name:COURNOYER-BAUM
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:J
Other - Last Name:COURNOYER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4105 S CARNEGIE PL
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-2360
Mailing Address - Country:US
Mailing Address - Phone:605-323-2345
Mailing Address - Fax:605-323-2822
Practice Address - Street 1:4105 S CARNEGIE PL
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-2360
Practice Address - Country:US
Practice Address - Phone:605-323-2345
Practice Address - Fax:605-323-2822
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPCMH2106101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6575820Medicaid