Provider Demographics
NPI:1770241903
Name:BLACK, KIMBERLY ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:BLACK
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 1:268 MOCKINGBIRD RD
Mailing Address - Street 2:
Mailing Address - City:SWANNANOA
Mailing Address - State:NC
Mailing Address - Zip Code:28778-3718
Mailing Address - Country:US
Mailing Address - Phone:828-206-5876
Mailing Address - Fax:
Practice Address - Street 1:268 MOCKINGBIRD RD
Practice Address - Street 2:
Practice Address - City:SWANNANOA
Practice Address - State:NC
Practice Address - Zip Code:28778-3718
Practice Address - Country:US
Practice Address - Phone:828-206-5876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-05
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA112151041C0700X
NCC0102591041C0700X
GACSW0058281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical