Provider Demographics
NPI:1710461959
Name:FOTTA, KIMBERLY R
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:FOTTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:KENDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1501 MADISON RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1706
Mailing Address - Country:US
Mailing Address - Phone:513-354-5200
Mailing Address - Fax:513-354-7115
Practice Address - Street 1:1501 MADISON RD
Practice Address - Street 2:
Practice Address - City:WALNUT HILLS
Practice Address - State:OH
Practice Address - Zip Code:45206-1706
Practice Address - Country:US
Practice Address - Phone:513-354-5200
Practice Address - Fax:513-354-7115
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2303788101YP2500X
OHC.2103649101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00000OtherLICENSURE BOARD