Provider Demographics
NPI:1710488994
Name:SUPMAN, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SUPMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 E WILSON BRIDGE RD STE A5
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:71 E WILSON BRIDGE RD STE A5
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2358
Practice Address - Country:US
Practice Address - Phone:614-547-9233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
E.2001661101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional