Provider Demographics
NPI:1497516173
Name:KIMBLE, SHANEQUA (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANEQUA
Middle Name:
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHANEQUA
Other - Middle Name:KIMBLE
Other - Last Name:STEPPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:301 LUCY LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-8506
Mailing Address - Country:US
Mailing Address - Phone:678-557-1968
Mailing Address - Fax:
Practice Address - Street 1:301 LUCY LN
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-8506
Practice Address - Country:US
Practice Address - Phone:678-557-1968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9291104100000X
RICSW035491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker