Provider Demographics
NPI:1548210404
Name:HIOTT, KIMBERLY L
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:L
Last Name:HIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:L
Other - Last Name:PESCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3617 BRASELTON HWY STE 104
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-4667
Mailing Address - Country:US
Mailing Address - Phone:678-549-2255
Mailing Address - Fax:770-783-8927
Practice Address - Street 1:3617 BRASELTON HWY STE 104
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-4667
Practice Address - Country:US
Practice Address - Phone:678-549-2255
Practice Address - Fax:770-783-8927
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4710101YP2500X
GALPC005898101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003124243AMedicaid