Provider Demographics
NPI:1922312412
Name:ELLINGSON, KIMBERLY (LMHC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ELLINGSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:2750 SAINT FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5644
Mailing Address - Country:US
Mailing Address - Phone:192-728-9223
Mailing Address - Fax:319-272-8929
Practice Address - Street 1:2750 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5644
Practice Address - Country:US
Practice Address - Phone:319-272-8922
Practice Address - Fax:319-272-8929
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001318101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA074575Medicaid