Provider Demographics
NPI:1710855226
Name:BACKTOLIFE360
Entity type:Organization
Organization Name:BACKTOLIFE360
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBROUGH-EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:713-478-1133
Mailing Address - Street 1:7007 FALL CREEK LN
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-3578
Mailing Address - Country:US
Mailing Address - Phone:713-478-1133
Mailing Address - Fax:
Practice Address - Street 1:7007 FALL CREEK LN
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-3578
Practice Address - Country:US
Practice Address - Phone:713-478-1133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty