Provider Demographics
NPI:1881010635
Name:FORD, KIMBERLY RENEE' (LCMHC, LPC, LCAS-A)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:RENEE'
Last Name:FORD
Suffix:
Gender:F
Credentials:LCMHC, LPC, LCAS-A
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 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 KIMEL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6951
Practice Address - Country:US
Practice Address - Phone:336-718-3550
Practice Address - Fax:336-277-1825
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9273101YM0800X, 101YP2500X
NC3547101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)