Provider Demographics
NPI:1851383889
Name:DALLAS, KIM CLARISSA (LMSW)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:CLARISSA
Last Name:DALLAS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:CLARISSA
Other - Last Name:WEEKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:239 GOLDEN HILL LN
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-6441
Mailing Address - Country:US
Mailing Address - Phone:845-340-4125
Mailing Address - Fax:845-340-4094
Practice Address - Street 1:239 GOLDEN HILL LN
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-6441
Practice Address - Country:US
Practice Address - Phone:845-340-4135
Practice Address - Fax:845-340-4094
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073220104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker