Provider Demographics
NPI:1720573512
Name:KIMBERLY LEDWA, LLC
Entity Type:Organization
Organization Name:KIMBERLY LEDWA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/COUNSELOR SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:O
Authorized Official - Last Name:LEDWA
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, ACADC
Authorized Official - Phone:208-376-5683
Mailing Address - Street 1:2971 E COPPER POINT DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9276
Mailing Address - Country:US
Mailing Address - Phone:208-376-5683
Mailing Address - Fax:208-376-5690
Practice Address - Street 1:2971 E COPPER POINT DR STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9276
Practice Address - Country:US
Practice Address - Phone:208-376-5683
Practice Address - Fax:208-376-5690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-5328101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty