Provider Demographics
NPI:1598015950
Name:PENDERGRASS, KIMBERLY (LICSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 S. W. HOLDEN STREET
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126
Mailing Address - Country:US
Mailing Address - Phone:206-933-7000
Mailing Address - Fax:
Practice Address - Street 1:2600 S. W. HOLDEN STREET
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126
Practice Address - Country:US
Practice Address - Phone:206-933-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW600982941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical