Provider Demographics
NPI:1992053771
Name:ASNER-SELF, KIMBERLY KAYE (EDD, NCC, LCPC)
Entity type:Individual
Prefix:PROF
First Name:KIMBERLY
Middle Name:KAYE
Last Name:ASNER-SELF
Suffix:
Gender:F
Credentials:EDD, NCC, LCPC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:625 WHAM DR
Mailing Address - Street 2:MAIL CODE 4618
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-4313
Mailing Address - Country:US
Mailing Address - Phone:618-453-2311
Mailing Address - Fax:618-453-7110
Practice Address - Street 1:109 LOU ANN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3733
Practice Address - Country:US
Practice Address - Phone:618-988-1330
Practice Address - Fax:618-988-8321
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.004440101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.004440OtherLICENSED CLINICAL PROFESSION COUNSELOR