Provider Demographics
NPI:1619288537
Name:WACASTER, KIMBERLY LIND (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LIND
Last Name:WACASTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LIND
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:4650 HAWTHORNE RD
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2376
Mailing Address - Country:US
Mailing Address - Phone:208-237-9833
Mailing Address - Fax:208-237-1800
Practice Address - Street 1:4650 HAWTHORNE RD
Practice Address - Street 2:SUITE 3B
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2376
Practice Address - Country:US
Practice Address - Phone:208-237-9833
Practice Address - Fax:208-237-1800
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-27911101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health