Healthcare Provider Details

I. General information

NPI: 1952883480
Provider Name (Legal Business Name): KIMBERLY DAWN DURHAM LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2018
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 N 4TH ST
LONGVIEW TX
75601-5436
US

IV. Provider business mailing address

950 N 4TH ST
LONGVIEW TX
75601-5436
US

V. Phone/Fax

Practice location:
  • Phone: 903-757-1106
  • Fax: 903-757-6076
Mailing address:
  • Phone: 903-757-1106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number75106
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: