Provider Demographics
NPI:1467851394
Name:KIRK, KIMBERLY (PC-CR, LCDC III)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KIRK
Suffix:
Gender:F
Credentials:PC-CR, LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2796 MACK RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5129
Mailing Address - Country:US
Mailing Address - Phone:513-861-1100
Mailing Address - Fax:
Practice Address - Street 1:2796 MACK RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5129
Practice Address - Country:US
Practice Address - Phone:513-861-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDC.141082-3101YA0400X
OHC.0500898-CR101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)