Provider Demographics
NPI:1477024420
Name:HENRY CLARK, KIMBERLY M (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:HENRY CLARK
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 1:58 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-3410
Mailing Address - Country:US
Mailing Address - Phone:215-870-9699
Mailing Address - Fax:
Practice Address - Street 1:58 CHERRY ST
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-3410
Practice Address - Country:US
Practice Address - Phone:215-870-9699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0194801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty