Provider Demographics
NPI:1427355171
Name:BAZO, KIMBERLEE GAIL (LMHC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLEE
Middle Name:GAIL
Last Name:BAZO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:KIMBERLEE
Other - Middle Name:GAIL
Other - Last Name:REAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 CREEK CROSSING BLVD
Mailing Address - Street 2:
Mailing Address - City:HAINESPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:08036-2765
Mailing Address - Country:US
Mailing Address - Phone:253-229-5535
Mailing Address - Fax:
Practice Address - Street 1:101 CREEK CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:HAINESPORT
Practice Address - State:NJ
Practice Address - Zip Code:08036-2765
Practice Address - Country:US
Practice Address - Phone:253-229-5535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60165744101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA12189026OtherCAQH