Provider Demographics
NPI:1346546132
Name:RUST, KIMBERLY LOCKWOOD (PHD)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:LOCKWOOD
Last Name:RUST
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BOWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:930 N FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-2718
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:118 1/2 N. WOODLAND BLVD.
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720
Practice Address - Country:US
Practice Address - Phone:862-328-6233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW98601041C0700X
MO20200205011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical