Provider Demographics
NPI:1114104817
Name:SMITH, GRACE KIMBURI (LCSW)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:KIMBURI
Last Name:SMITH
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 1:7895 WATERWAY DR NW APT 306
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-4436
Mailing Address - Country:US
Mailing Address - Phone:828-808-4397
Mailing Address - Fax:
Practice Address - Street 1:7895 WATERWAY DR NW APT 306
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-4436
Practice Address - Country:US
Practice Address - Phone:828-808-4397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NCC008449104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC008449OtherNC LCSW CERTIFICATION