Provider Demographics
NPI:1386662773
Name:LAFOLLETTE, KIMBERLY M
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:LAFOLLETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:130 VINE STREET
Mailing Address - City:SHEPHERDSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40165-0690
Mailing Address - Country:US
Mailing Address - Phone:502-589-1100
Mailing Address - Fax:502-589-8771
Practice Address - Street 1:101 W MUHAMMAD ALI BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1423
Practice Address - Country:US
Practice Address - Phone:502-589-8600
Practice Address - Fax:502-589-8771
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTEMP-2005-65103T00000X
KY1452103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK198680Medicare PIN