Provider Demographics
NPI:1922689504
Name:BURTON, KIMBERLY CORSON (LMSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CORSON
Last Name:BURTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:SUE
Other - Last Name:CORSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:161 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2879
Mailing Address - Country:US
Mailing Address - Phone:631-360-7578
Mailing Address - Fax:
Practice Address - Street 1:161 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2879
Practice Address - Country:US
Practice Address - Phone:631-360-7578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111349-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker