Provider Demographics
NPI:1538517248
Name:CANNON, KIMBERLEE LOCKWOOD (LISW-CP)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:LOCKWOOD
Last Name:CANNON
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:KIMBERLEE
Other - Middle Name:ALLEN
Other - Last Name:LOCKWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW-CP
Mailing Address - Street 1:2711 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2711 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6818
Practice Address - Country:US
Practice Address - Phone:803-726-9460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
SC11700104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical