Provider Demographics
NPI:1841576188
Name:DURHAM, KIMBERLY (LADC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:DURHAM
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6822 NW FAIRCLOUD DR
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-1280
Mailing Address - Country:US
Mailing Address - Phone:918-269-8180
Mailing Address - Fax:
Practice Address - Street 1:1320 NW HOMESTEAD DR
Practice Address - Street 2:SUITE G
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5243
Practice Address - Country:US
Practice Address - Phone:580-355-8883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK639101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)