Provider Demographics
NPI:1730749789
Name:GOODLOE, KIMBERLEY KAVANAUGH (MS)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLEY
Middle Name:KAVANAUGH
Last Name:GOODLOE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 S HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-2935
Mailing Address - Country:US
Mailing Address - Phone:606-677-4068
Mailing Address - Fax:
Practice Address - Street 1:2441 S HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-2935
Practice Address - Country:US
Practice Address - Phone:606-677-4068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY248395103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist