Provider Demographics
NPI:1396923249
Name:LANDERO, KIMBERLY S (LISAC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:S
Last Name:LANDERO
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 N EASTERN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-2885
Mailing Address - Country:US
Mailing Address - Phone:702-598-2020
Mailing Address - Fax:702-598-2018
Practice Address - Street 1:730 N EASTERN AVE STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-2885
Practice Address - Country:US
Practice Address - Phone:702-598-2020
Practice Address - Fax:702-598-2018
Is Sole Proprietor?:No
Enumeration Date:2008-02-02
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV00334-LC101YA0400X
NV01344106H00000X
AZ10263101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ10263OtherLISAC