Provider Demographics
NPI:1770066151
Name:DRAUGHON, KIM RENEA (MA)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:RENEA
Last Name:DRAUGHON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:RENEA
Other - Last Name:RUYBAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:8649 W 95TH DR
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80021-5322
Mailing Address - Country:US
Mailing Address - Phone:303-819-6425
Mailing Address - Fax:
Practice Address - Street 1:8649 W 95TH DR
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80021-5322
Practice Address - Country:US
Practice Address - Phone:303-819-6425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2647251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2647OtherLICENSE