Provider Demographics
NPI:1205693454
Name:SYLVEST, KIM LEO (SUDCC)
Entity type:Individual
Prefix:MR
First Name:KIM
Middle Name:LEO
Last Name:SYLVEST
Suffix:
Gender:M
Credentials:SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12241 ARROWHEAD ST APT 46
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-3868
Mailing Address - Country:US
Mailing Address - Phone:630-780-9264
Mailing Address - Fax:
Practice Address - Street 1:1701 ZONAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1065
Practice Address - Country:US
Practice Address - Phone:323-223-6298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15744101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty