Provider Demographics
NPI:1336296649
Name:FORRISTALL, KIMBERLY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:FORRISTALL
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 1488
Mailing Address - Street 2:2960 CHARTRES STREET
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-3488
Mailing Address - Country:US
Mailing Address - Phone:815-224-1610
Mailing Address - Fax:815-223-1634
Practice Address - Street 1:2960 CHARTRES ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-1097
Practice Address - Country:US
Practice Address - Phone:815-224-1610
Practice Address - Fax:815-223-1634
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208505Medicare ID - Type UnspecifiedMEDICARE PROVIDER