Provider Demographics
NPI:1720578024
Name:LUTE, KIMBERLY ANN (CDCA, QMHS)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:LUTE
Suffix:
Gender:F
Credentials:CDCA, QMHS
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:CROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1071 TONG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:45612-1500
Mailing Address - Country:US
Mailing Address - Phone:740-634-3094
Mailing Address - Fax:
Practice Address - Street 1:1071 TONG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:45612-1500
Practice Address - Country:US
Practice Address - Phone:740-634-3094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150150171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator