Healthcare Provider Details

I. General information

NPI: 1225535800
Provider Name (Legal Business Name): MRS. KIMBERLY E BROWDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY E BASS GORDON

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 E BOGARD RD
WASILLA AK
99654-4711
US

IV. Provider business mailing address

PO BOX 876741
WASILLA AK
99687-6741
US

V. Phone/Fax

Practice location:
  • Phone: 907-206-4301
  • Fax:
Mailing address:
  • Phone: 907-206-4301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1020986
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: