Provider Demographics
NPI:1043675275
Name:CHILDRESS, KIMBERLY LYNN (MA, LPC, LCMHCS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:MA, LPC, LCMHCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10430 HARRIS OAK BLVD STE L
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-7513
Mailing Address - Country:US
Mailing Address - Phone:704-360-3637
Mailing Address - Fax:704-200-9829
Practice Address - Street 1:10430 HARRIS OAK BLVD STE L
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-7513
Practice Address - Country:US
Practice Address - Phone:704-360-3637
Practice Address - Fax:704-200-9829
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6208101Y00000X
NCS15220101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEJ7GST1IO450JIHMedicaid