Provider Demographics
NPI:1770720583
Name:FAILES, KIMBERLY ANN (MS LPC LAT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:FAILES
Suffix:
Gender:F
Credentials:MS LPC LAT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:FAILES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS LCPC
Mailing Address - Street 1:378 FALLS AVE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3373
Mailing Address - Country:US
Mailing Address - Phone:208-293-8062
Mailing Address - Fax:208-293-8082
Practice Address - Street 1:378 FALLS AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3373
Practice Address - Country:US
Practice Address - Phone:208-293-8062
Practice Address - Fax:208-293-8082
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT 269101YA0400X, 101YM0800X
WYLPC 732101YP2500X, 101YM0800X
IDLCPC 5870101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
WYLPC732101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health