Provider Demographics
NPI:1477724573
Name:SACRA, KIMBERLY E (LPC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:E
Last Name:SACRA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:E
Other - Last Name:MEDLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:3003 N CENTRAL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2902
Mailing Address - Country:US
Mailing Address - Phone:602-685-6000
Mailing Address - Fax:602-302-7925
Practice Address - Street 1:1802 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-8134
Practice Address - Country:US
Practice Address - Phone:602-685-6000
Practice Address - Fax:602-258-6140
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-10391101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ315348Medicaid