Provider Demographics
NPI:1518933324
Name:BROGDEN, KIMBERLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BROGDEN
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 1:208 MALLOY ST STE E
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4478
Mailing Address - Country:US
Mailing Address - Phone:919-778-5594
Mailing Address - Fax:919-778-5633
Practice Address - Street 1:208 MALLOY ST
Practice Address - Street 2:SUITE E
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-4478
Practice Address - Country:US
Practice Address - Phone:919-778-5594
Practice Address - Fax:919-778-5633
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC001691101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106132Medicaid
NC200173438OtherTAX ID
NC6106132Medicaid