Healthcare Provider Details

I. General information

NPI: 1720135395
Provider Name (Legal Business Name): KIMBERLY N BRISTOW LMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY N BUCK LCPC

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5120 E BURNTE PEAK ST
NAMPA ID
83687-7108
US

IV. Provider business mailing address

5120 E BURNTE PEAK ST
NAMPA ID
83687-7108
US

V. Phone/Fax

Practice location:
  • Phone: 208-317-3092
  • Fax:
Mailing address:
  • Phone: 208-317-3092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3919
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC9971574
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: