Healthcare Provider Details

I. General information

NPI: 1457515157
Provider Name (Legal Business Name): KIMBERLY LYNN CLICQUENNOI LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM SYNAN

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 S MADISON BLVD SUITE C2
ROXBORO NC
27573-5485
US

IV. Provider business mailing address

3210 FAIRHILL DR
RALEIGH NC
27612-3215
US

V. Phone/Fax

Practice location:
  • Phone: 336-597-2065
  • Fax: 336-597-2116
Mailing address:
  • Phone: 919-256-0824
  • Fax: 919-256-0833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7108
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: