Provider Demographics
NPI:1235760315
Name:DEROSIER, KIMBERLEE MARTHA (LADC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLEE
Middle Name:MARTHA
Last Name:DEROSIER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18699 DYLAN DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-7070
Mailing Address - Country:US
Mailing Address - Phone:906-369-0421
Mailing Address - Fax:
Practice Address - Street 1:7300 147TH ST W
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7541
Practice Address - Country:US
Practice Address - Phone:952-234-8566
Practice Address - Fax:952-997-3026
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
305644101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)