Provider Demographics
NPI:1700220399
Name:STAUFFER, KIMM A (LICDC)
Entity Type:Individual
Prefix:
First Name:KIMM
Middle Name:A
Last Name:STAUFFER
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:TACKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4670
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43058-4670
Mailing Address - Country:US
Mailing Address - Phone:740-522-8477
Mailing Address - Fax:740-788-3424
Practice Address - Street 1:74 GRANVILLE ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-4910
Practice Address - Country:US
Practice Address - Phone:740-522-8477
Practice Address - Fax:740-788-3424
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHICDC.954408-CS101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)