Provider Demographics
NPI:1437625233
Name:MAUCK, KIMBERLY LYNN (LPC, CSAC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:MAUCK
Suffix:
Gender:F
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23229-5918
Mailing Address - Country:US
Mailing Address - Phone:804-317-3571
Mailing Address - Fax:
Practice Address - Street 1:8527 MAYLAND DR STE 103
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-4753
Practice Address - Country:US
Practice Address - Phone:804-363-2583
Practice Address - Fax:804-510-0244
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007914101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional