Provider Demographics
NPI:1194136879
Name:GO, KIMBERLY (PCC, PSC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GO
Suffix:
Gender:F
Credentials:PCC, PSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 1/2 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-1925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 WILDCAT DR
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:OH
Practice Address - Zip Code:44851-9262
Practice Address - Country:US
Practice Address - Phone:419-929-1586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE2114101YP2500X
OHOH1239462101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool