Provider Demographics
NPI:1689646192
Name:COLLURO, KIMBERLEY CANUPP (LPC)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:CANUPP
Last Name:COLLURO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 GOLF VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-4043
Mailing Address - Country:US
Mailing Address - Phone:770-654-6836
Mailing Address - Fax:
Practice Address - Street 1:26 CHARLIE SMITH RD
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-2500
Practice Address - Country:US
Practice Address - Phone:770-654-6836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004144101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional