Provider Demographics
NPI:1487117966
Name:MOORE, KIMBERLY DAWN (MA, LIMHP, CPC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, LIMHP, CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6315 AYLESWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-1276
Mailing Address - Country:US
Mailing Address - Phone:402-416-1304
Mailing Address - Fax:
Practice Address - Street 1:6315 AYLESWORTH AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-1276
Practice Address - Country:US
Practice Address - Phone:402-416-1304
Practice Address - Fax:402-347-0909
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2101101Y00000X
NE1614101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor