Provider Demographics
NPI:1770215550
Name:GILLENWATER, KIMBERLY N
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:GILLENWATER
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 1:11010 DAVID TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1574
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11010 DAVID TAYLOR DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1574
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst