1356575476 NPI number — MS. KIMBERLY SHAWN UNDERDUE LCSW

Table of content: MS. KIMBERLY SHAWN UNDERDUE LCSW (NPI 1356575476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356575476 NPI number — MS. KIMBERLY SHAWN UNDERDUE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UNDERDUE
Provider First Name:
KIMBERLY
Provider Middle Name:
SHAWN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1356575476
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1071 LAUREL RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCDONOUGH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30252-8432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-851-9509
Provider Business Mailing Address Fax Number:
678-623-3748

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 BURKE ST
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
STOCKBRIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30281-3463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-389-9886
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2009

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: 1041C0700X , with the licence number:  CSW004368 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 315091169A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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