Provider Demographics
NPI:1831635010
Name:SOUTHWORTH, KIMBERLY
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:6632 MIDDLE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:12850-2413
Mailing Address - Country:US
Mailing Address - Phone:518-424-4642
Mailing Address - Fax:
Practice Address - Street 1:1801 6TH AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-3478
Practice Address - Country:US
Practice Address - Phone:518-545-0258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72 0962571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical