Provider Demographics
NPI:1316096563
Name:LANDROCHE, KIMBERLY DAWN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:LANDROCHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2972 W TALARA LN
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-4809
Mailing Address - Country:US
Mailing Address - Phone:520-406-5196
Mailing Address - Fax:520-721-0069
Practice Address - Street 1:2972 W TALARA LN
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85742-4809
Practice Address - Country:US
Practice Address - Phone:520-406-5196
Practice Address - Fax:520-721-0069
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ893249Medicaid