Provider Demographics
NPI:1629378955
Name:OSBORNE, KIMBERLY JILL (EDS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JILL
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:EDS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1269 PARKER RD SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5957
Mailing Address - Country:US
Mailing Address - Phone:404-234-0546
Mailing Address - Fax:770-761-9070
Practice Address - Street 1:1269 PARKER RD SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5957
Practice Address - Country:US
Practice Address - Phone:404-234-0546
Practice Address - Fax:770-761-9070
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006170101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112503AMedicaid
GA003188998AMedicaid
GA003112500AMedicaid