Provider Demographics
NPI:1073162608
Name:LOSQUADRO, KIM M (MS MA)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:LOSQUADRO
Suffix:
Gender:F
Credentials:MS MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1961 FONTAINEBLEAU CT
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-2995
Mailing Address - Country:US
Mailing Address - Phone:850-261-4963
Mailing Address - Fax:850-409-4963
Practice Address - Street 1:107 HUGHES ST NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4455
Practice Address - Country:US
Practice Address - Phone:850-261-4963
Practice Address - Fax:850-409-4963
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLMHC16703101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health