Provider Demographics
NPI:1992180764
Name:WHITMAN, KIMBERLY BROOKE (MSSW, LCSW, LCASA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:BROOKE
Last Name:WHITMAN
Suffix:
Gender:F
Credentials:MSSW, LCSW, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1894
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:132 POPLAR GROVE CONNECTOR STE B
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5915
Practice Address - Country:US
Practice Address - Phone:828-264-8759
Practice Address - Fax:828-264-5754
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-23647101YA0400X
NCP0085851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1992180764Medicaid