Provider Demographics
NPI:1467460527
Name:PROBECK, KIMBERLY ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:PROBECK
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 1:18 NORWOOD PL
Mailing Address - Street 2:
Mailing Address - City:WHEATLEY HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11798-1029
Mailing Address - Country:US
Mailing Address - Phone:631-491-0741
Mailing Address - Fax:
Practice Address - Street 1:18 NORWOOD PL
Practice Address - Street 2:
Practice Address - City:WHEATLEY HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11798-1029
Practice Address - Country:US
Practice Address - Phone:631-491-0741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0443171104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02754098Medicaid
NY02754098Medicaid