Provider Demographics
NPI:1093884108
Name:SCOTT, KIMBERLY ANTOINE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANTOINE
Last Name:SCOTT
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:PO BOX 985
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27588-0985
Mailing Address - Country:US
Mailing Address - Phone:919-673-7816
Mailing Address - Fax:919-640-1901
Practice Address - Street 1:112 S. BROOKS ST.
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-5008
Practice Address - Country:US
Practice Address - Phone:919-324-7361
Practice Address - Fax:919-640-1901
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0046661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002801Medicaid