Provider Demographics
NPI:1760420459
Name:BECKER, KIMBERLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BECKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:589 RUE LA GRANDE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3135
Mailing Address - Country:US
Mailing Address - Phone:270-307-3672
Mailing Address - Fax:253-681-0825
Practice Address - Street 1:240 W DIXIE AVE
Practice Address - Street 2:SUITE 5-B
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1586
Practice Address - Country:US
Practice Address - Phone:207-307-3276
Practice Address - Fax:253-681-0825
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30605018Medicaid
11574939OtherCAQH
KY000000495963OtherANTHEM
KY0762261Medicare PIN
KY000000495963OtherANTHEM
KY30605018Medicaid
KY00207015Medicare PIN
KY0762357Medicare PIN
KY0763557Medicare PIN
KYK047850Medicare PIN
11574939OtherCAQH
KY00205015Medicare PIN
KY0974730Medicare PIN
KY00201017Medicare PIN
KY00200017Medicare PIN