Provider Demographics
NPI:1104171453
Name:KIMBER, SONYA RENA (CAC)
Entity type:Individual
Prefix:MS
First Name:SONYA
Middle Name:RENA
Last Name:KIMBER
Suffix:
Gender:F
Credentials:CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64843
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70896-4843
Mailing Address - Country:US
Mailing Address - Phone:225-928-5842
Mailing Address - Fax:225-928-9906
Practice Address - Street 1:2036 WOODDALE BLVD
Practice Address - Street 2:SUITE S
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-1518
Practice Address - Country:US
Practice Address - Phone:225-928-5842
Practice Address - Fax:225-928-9906
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA489101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)