Healthcare Provider Details

I. General information

NPI: 1134765266
Provider Name (Legal Business Name): KIMBERLY IRENE HOAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 W COTA ST
SHELTON WA
98584-2265
US

IV. Provider business mailing address

326 CHOKER ST SE # B
LACEY WA
98503-1529
US

V. Phone/Fax

Practice location:
  • Phone: 503-754-5467
  • Fax:
Mailing address:
  • Phone: 360-491-9616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: