Provider Demographics
NPI:1164408936
Name:YEAGLE, KIMBERLY KAY (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KAY
Last Name:YEAGLE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 OSAGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-5476
Mailing Address - Country:US
Mailing Address - Phone:573-474-2984
Mailing Address - Fax:
Practice Address - Street 1:1902 OSAGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-5476
Practice Address - Country:US
Practice Address - Phone:573-474-2984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0044611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497695130Medicaid
MO004461OtherSTATE OF MISSOURI LICENSE