Provider Demographics
NPI:1750832135
Name:CHIPEMBA, KELLY (LISW-S, LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CHIPEMBA
Suffix:
Gender:F
Credentials:LISW-S, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 MDG
Mailing Address - Street 2:5955 ZEAMER AVE
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506
Mailing Address - Country:US
Mailing Address - Phone:928-755-4586
Mailing Address - Fax:
Practice Address - Street 1:673 MDG
Practice Address - Street 2:5955 ZEAMER AVE
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506
Practice Address - Country:US
Practice Address - Phone:928-674-7166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0009969-S101YA0400X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)