Provider Demographics
NPI:1033499959
Name:SLADE, KIMBERLY (PLCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SLADE
Suffix:
Gender:F
Credentials:PLCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 GILMER ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-3860
Mailing Address - Country:US
Mailing Address - Phone:336-347-7415
Mailing Address - Fax:336-347-7419
Practice Address - Street 1:232 GILMER ST
Practice Address - Street 2:SUITE 206
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-3860
Practice Address - Country:US
Practice Address - Phone:336-347-7415
Practice Address - Fax:336-347-7419
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP005551104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker