Provider Demographics
NPI:1972055564
Name:NUSBAUM, KIMBERLEY IRENE (LICSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:IRENE
Last Name:NUSBAUM
Suffix:
Gender:F
Credentials:LICSW
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 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:253-681-6603
Mailing Address - Fax:206-764-8005
Practice Address - Street 1:2502 E FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3965
Practice Address - Country:US
Practice Address - Phone:360-831-0904
Practice Address - Fax:360-433-9917
Is Sole Proprietor?:No
Enumeration Date:2016-10-29
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW612947191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2115400Medicaid