Provider Demographics
NPI:1659776912
Name:NEESE, KIM L (LPC, BCCC, CADC II,)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:NEESE
Suffix:
Gender:F
Credentials:LPC, BCCC, CADC II,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 SMOKEY RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-9083
Mailing Address - Country:US
Mailing Address - Phone:706-594-1192
Mailing Address - Fax:
Practice Address - Street 1:406 RIDLEY AVE
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2232
Practice Address - Country:US
Practice Address - Phone:706-594-1192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA423101YA0400X
GALPC007660101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003169076AMedicaid