MEDICARE: KIM CLEVELAND THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1922600055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIM CLEVELAND THERAPY, LLC

Provider Business Mailing Address
First Line	:	1511 W 3RD AVE STE 104
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31707-3658
Country	:	US
Telephone Number	:	229-483-5050
Fax Number	:	229-483-1103

Provider Business Practice Location Address
First Line	:	1511 W 3RD AVE STE 104
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31707-3658
Country	:	US
Telephone Number	:	229-483-5050
Fax Number	:	229-485-1103

Authorized Official
Title or Position	:	OWNER
Name	:	LISA KIM CLEVELAND
Credential	:	LPC,CAADC
Telephone Number	:	229-483-5050

Provider Enumeration Date	:	11/13/2020
Last Update Date	:	02/04/2021

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Directions to “KIM CLEVELAND THERAPY, LLC ” Practice Location

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