Provider Demographics
NPI:1184839649
Name:TAMBASCO-JANKUNAS, KIMBERLY L (LCSW-R)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:TAMBASCO-JANKUNAS
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5982 RHODES RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-4128
Mailing Address - Country:US
Mailing Address - Phone:330-673-1347
Mailing Address - Fax:330-678-3677
Practice Address - Street 1:172 OAK LEAF CIR
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-5835
Practice Address - Country:US
Practice Address - Phone:330-416-0425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079547R1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHTASW29891Medicare ID - Type UnspecifiedMEDICARE