Provider Demographics
NPI:1720024102
Name:YADA, KIMBERLY D (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:YADA
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:YADA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:1090 ARNOLD DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK AIR FORCE BASE
Mailing Address - State:AR
Mailing Address - Zip Code:72099-4933
Mailing Address - Country:US
Mailing Address - Phone:501-987-7377
Mailing Address - Fax:501-987-8852
Practice Address - Street 1:1090 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK AIR FORCE BASE
Practice Address - State:AR
Practice Address - Zip Code:72099-4933
Practice Address - Country:US
Practice Address - Phone:501-987-7377
Practice Address - Fax:501-987-8852
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-9891041C0700X
1041C0700X
AR989- C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR07020013900OtherQUAL CHOICE
AR4572633OtherAETNA
AR5S661OtherBCBS PROVIDER NUMBER