Provider Demographics
NPI:1639358161
Name:WASOSKI, KIMBERLY SUE (LMHC, LCAC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:SUE
Last Name:WASOSKI
Suffix:
Gender:F
Credentials:LMHC, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 E. JEFFERSON BLVD.
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-2733
Mailing Address - Country:US
Mailing Address - Phone:574-222-2466
Mailing Address - Fax:574-222-2468
Practice Address - Street 1:3220 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-3028
Practice Address - Country:US
Practice Address - Phone:574-222-2466
Practice Address - Fax:574-222-2468
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000873A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000542441OtherUNICARE
IN200375890AMedicaid
IN000000542441OtherANTHEM