Provider Demographics
NPI:1346072337
Name:TRUITT, KIMBERLY LYNN (LAC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:TRUITT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9071 N WAGON SPOKE CT
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-0004
Mailing Address - Country:US
Mailing Address - Phone:520-275-2745
Mailing Address - Fax:
Practice Address - Street 1:125 E MABEL ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-6654
Practice Address - Country:US
Practice Address - Phone:520-524-4757
Practice Address - Fax:520-844-6585
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-17
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22754101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health