Provider Demographics
NPI:1417064320
Name:DISMUKES, KIM RICHARD (LPC)
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:RICHARD
Last Name:DISMUKES
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WESTSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-1908
Mailing Address - Country:US
Mailing Address - Phone:334-793-2237
Mailing Address - Fax:334-712-6256
Practice Address - Street 1:100 WESTSIDE DR
Practice Address - Street 2:
Practice Address - City:DOTHAM
Practice Address - State:AL
Practice Address - Zip Code:36303
Practice Address - Country:US
Practice Address - Phone:334-793-2237
Practice Address - Fax:334-712-6256
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL459101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional