Provider Demographics
NPI:1609021567
Name:CAMPOLONG, KIMBERLY A (LMSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:CAMPOLONG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2468
Mailing Address - Country:US
Mailing Address - Phone:586-753-0405
Mailing Address - Fax:586-753-0404
Practice Address - Street 1:132 TRUMBULL ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MI
Practice Address - Zip Code:48079-5372
Practice Address - Country:US
Practice Address - Phone:810-329-5340
Practice Address - Fax:810-329-8964
Is Sole Proprietor?:No
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801069151104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker