1457515157 NPI number — KIMBERLY LYNN CLICQUENNOI LCMHC

Table of content: KIMBERLY LYNN CLICQUENNOI LCMHC (NPI 1457515157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457515157 NPI number — KIMBERLY LYNN CLICQUENNOI LCMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLICQUENNOI
Provider First Name:
KIMBERLY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SYNAN
Provider Other First Name:
KIM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457515157
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3210 FAIRHILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27612-3215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-256-0824
Provider Business Mailing Address Fax Number:
919-256-0833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
355 S MADISON BLVD
Provider Second Line Business Practice Location Address:
SUITE C2
Provider Business Practice Location Address City Name:
ROXBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27573-5485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-597-2065
Provider Business Practice Location Address Fax Number:
336-597-2116
Provider Enumeration Date:
07/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  7108 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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