Provider Demographics
NPI:1275887440
Name:BENNETT, KIMBERLY BROOKE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:BROOKE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:BROOKE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1005 SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2123
Mailing Address - Country:US
Mailing Address - Phone:912-389-4188
Mailing Address - Fax:
Practice Address - Street 1:1005 SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533
Practice Address - Country:US
Practice Address - Phone:912-389-4188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA865101YA0400X
GAMSW005671104100000X
GACSW0054271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker