Provider Demographics
NPI:1093128480
Name:CHRISTLY, KIMBERLY (LICSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CHRISTLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:9618 SE DRIFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-9712
Mailing Address - Country:US
Mailing Address - Phone:417-827-4503
Mailing Address - Fax:
Practice Address - Street 1:9618 SE DRIFTWOOD DR
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98367-9712
Practice Address - Country:US
Practice Address - Phone:417-827-4503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW 603400011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical