Healthcare Provider Details

I. General information

NPI: 1154411791
Provider Name (Legal Business Name): SAGE KIMBLE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 MORNINGSIDE DR NE
ALBUQUERQUE NM
87108-1035
US

IV. Provider business mailing address

343 MORNINGSIDE DR NE
ALBUQUERQUE NM
87108-1035
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-4727
  • Fax: 505-266-2236
Mailing address:
  • Phone: 505-265-4727
  • Fax: 505-266-2236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1356
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: