Provider Demographics
NPI:1518503168
Name:KLEISCH, KIMBERLY (LCAS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KLEISCH
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-2340
Mailing Address - Country:US
Mailing Address - Phone:336-255-7131
Mailing Address - Fax:336-217-8847
Practice Address - Street 1:810 WARREN ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-2340
Practice Address - Country:US
Practice Address - Phone:336-255-7131
Practice Address - Fax:336-217-8847
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24189101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC24189OtherNORTH CAROLINA