Provider Demographics
NPI:1093761900
Name:CHARBONEAU, KIMBERLY K (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
Last Name:CHARBONEAU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 NORTHAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-1726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:284 MAIN ST
Practice Address - Street 2:SUITE 320
Practice Address - City:SCHOHARIE
Practice Address - State:NY
Practice Address - Zip Code:12157-2118
Practice Address - Country:US
Practice Address - Phone:518-295-8336
Practice Address - Fax:518-295-8724
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0441421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00555784Medicaid
NY00555784Medicaid