Provider Demographics
NPI:1629692561
Name:FOSS, KIMBERLY BROOK
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BROOK
Last Name:FOSS
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 1:3619 W TULSA ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-4045
Mailing Address - Country:US
Mailing Address - Phone:480-371-5043
Mailing Address - Fax:
Practice Address - Street 1:17235 N 75TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-0831
Practice Address - Country:US
Practice Address - Phone:480-641-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-06
Last Update Date:2020-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health