Provider Demographics
NPI:1962795997
Name:NEWSOME, KIMBERLY ANITA (MA LCAS)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANITA
Last Name:NEWSOME
Suffix:
Gender:F
Credentials:MA LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 BROAD LEAF CIR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-3280
Mailing Address - Country:US
Mailing Address - Phone:919-789-9747
Mailing Address - Fax:919-786-9747
Practice Address - Street 1:1110 NAVAHO DR STE 125
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7352
Practice Address - Country:US
Practice Address - Phone:919-431-9874
Practice Address - Fax:919-431-9875
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1817101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health