Provider Demographics
NPI:1750665469
Name:SAMBOU, KIMBA (MA, LPA)
Entity Type:Individual
Prefix:
First Name:KIMBA
Middle Name:
Last Name:SAMBOU
Suffix:
Gender:F
Credentials:MA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 WESTGATE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2567
Mailing Address - Country:US
Mailing Address - Phone:919-402-8738
Mailing Address - Fax:919-403-6106
Practice Address - Street 1:3500 WESTGATE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2567
Practice Address - Country:US
Practice Address - Phone:919-402-8738
Practice Address - Fax:919-403-6106
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3557103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107722Medicaid