Provider Demographics
NPI:1295073039
Name:GRUENING MCNICKLE, KIMBERLEY LOUISE (LMHC)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:LOUISE
Last Name:GRUENING MCNICKLE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6512 20TH STREET CT W
Mailing Address - Street 2:SUITE B
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6212
Mailing Address - Country:US
Mailing Address - Phone:253-566-5559
Mailing Address - Fax:253-565-0274
Practice Address - Street 1:6512 20TH STREET CT W
Practice Address - Street 2:SUITE B
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6212
Practice Address - Country:US
Practice Address - Phone:253-566-5559
Practice Address - Fax:253-565-0274
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006744101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health