Provider Demographics
NPI:1871268466
Name:KIMBROUGH, SHATERA
Entity Type:Individual
Prefix:
First Name:SHATERA
Middle Name:
Last Name:KIMBROUGH
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 1:1111 BENFIELD BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-3004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 BENFIELD BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-3004
Practice Address - Country:US
Practice Address - Phone:443-414-9976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCP11772101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health