Provider Demographics
NPI:1790565687
Name:ROOT, KIMBERLY GAYLE (LPCA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:GAYLE
Last Name:ROOT
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:ROOT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCA
Mailing Address - Street 1:127 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2717
Mailing Address - Country:US
Mailing Address - Phone:646-331-7668
Mailing Address - Fax:
Practice Address - Street 1:998 BROOKS INDUSTRIAL RD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8154
Practice Address - Country:US
Practice Address - Phone:502-633-1315
Practice Address - Fax:502-633-1316
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY287602101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health