Provider Demographics
NPI:1841736899
Name:WELLIVER, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WELLIVER
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 1:903 NORTHEAST DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-7416
Mailing Address - Country:US
Mailing Address - Phone:704-896-7776
Mailing Address - Fax:
Practice Address - Street 1:10 CABARRUS AVE E STE 245
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4785
Practice Address - Country:US
Practice Address - Phone:704-343-5112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2023-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12709101YM0800X
NC12709101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health