Provider Demographics
NPI:1568834620
Name:FAWCETT, KIMBERLY G (MHS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:G
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 JOHNSON ST STE C
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-3650
Mailing Address - Country:US
Mailing Address - Phone:337-616-0225
Mailing Address - Fax:
Practice Address - Street 1:1615 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-3650
Practice Address - Country:US
Practice Address - Phone:337-616-0225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker