Provider Demographics
NPI:1447765268
Name:SHASHOUA, KIMBERLY VERED (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:VERED
Last Name:SHASHOUA
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 1:600 MERRIMON AVE APT 4B
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28804-3430
Mailing Address - Country:US
Mailing Address - Phone:828-398-4242
Mailing Address - Fax:
Practice Address - Street 1:600 MERRIMON AVE APT 4B
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28804-3430
Practice Address - Country:US
Practice Address - Phone:828-398-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2018-09-25
Deactivation Date:2017-12-04
Deactivation Code:
Reactivation Date:2018-09-19
Provider Licenses
StateLicense IDTaxonomies
NCC0114121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
82-3445036OtherIRS