Provider Demographics
NPI:1821193855
Name:HINES, KIMBERLY ALICE (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ALICE
Last Name:HINES
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:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:PSYCHIATRY
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-828-3129
Practice Address - Fax:804-828-7814
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040055571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010319277Medicaid
VAO802755MOtherOPTIMA HEALTH
VA196818OtherANTHEM
VA010206588Medicaid
VA010234166Medicaid
VA196817OtherANTHEM
VA010234468Medicaid