Provider Demographics
NPI:1457676561
Name:ELLIS, KIMBERLY KERZAN (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KERZAN
Last Name:ELLIS
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 1:1000 W THARPE ST STE 7
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-5300
Mailing Address - Country:US
Mailing Address - Phone:850-561-8060
Mailing Address - Fax:850-561-1143
Practice Address - Street 1:1000 W THARPE ST STE 7
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-5300
Practice Address - Country:US
Practice Address - Phone:850-561-8060
Practice Address - Fax:850-561-1143
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW47051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical