Provider Demographics
NPI:1417917758
Name:WORMUTH, KIMBERLY (LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WORMUTH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 HAIRSTON ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-4137
Mailing Address - Country:US
Mailing Address - Phone:434-793-4931
Mailing Address - Fax:434-799-3100
Practice Address - Street 1:245 HAIRSTON ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-4137
Practice Address - Country:US
Practice Address - Phone:434-793-4931
Practice Address - Fax:434-799-3100
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003094101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945085Medicaid