Provider Demographics
NPI:1013224336
Name:KIMBERLING, MELISSA SAMPLES (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:SAMPLES
Last Name:KIMBERLING
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:MELISSA
Other - Middle Name:SAMPLES
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:24 JAMESON CT
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-1629
Mailing Address - Country:US
Mailing Address - Phone:631-754-5431
Mailing Address - Fax:
Practice Address - Street 1:24 JAMESON CT
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-1629
Practice Address - Country:US
Practice Address - Phone:631-754-5431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO41152-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool