Provider Demographics
NPI:1477854651
Name:SIRDEVAN, KIMBERLY STALLINGS (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:STALLINGS
Last Name:SIRDEVAN
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 1:6780 PATANIA WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5798
Mailing Address - Country:US
Mailing Address - Phone:904-805-0850
Mailing Address - Fax:904-805-9925
Practice Address - Street 1:6780 PATANIA WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5798
Practice Address - Country:US
Practice Address - Phone:904-805-0850
Practice Address - Fax:904-805-9925
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW94361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical