Healthcare Provider Details

I. General information

NPI: 1790565687
Provider Name (Legal Business Name): KIMBERLY GAYLE ROOT LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM ROOT LPCA

II. Dates (important events)

Enumeration Date: 09/29/2023
Last Update Date: 09/29/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

998 BROOKS INDUSTRIAL RD
SHELBYVILLE KY
40065-8154
US

IV. Provider business mailing address

127 PENNSYLVANIA AVE
LOUISVILLE KY
40206-2717
US

V. Phone/Fax

Practice location:
  • Phone: 502-633-1315
  • Fax: 502-633-1316
Mailing address:
  • Phone: 646-331-7668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number287602
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: