Provider Demographics
NPI:1295854339
Name:COMMISSIONG, KIMBALIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIMBALIE
Middle Name:
Last Name:COMMISSIONG
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:KIMBALIE
Other - Middle Name:
Other - Last Name:COMMISSIONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1317 EDGEWATER DR # 5519
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1317 EDGEWATER DR # 5519
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-6350
Practice Address - Country:US
Practice Address - Phone:407-565-7310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2025-04-08
Deactivation Date:2019-06-03
Deactivation Code:
Reactivation Date:2020-04-29
Provider Licenses
StateLicense IDTaxonomies
COCSW.09930266104100000X
TX1150541041C0700X
FLSW73751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12958544339OtherNPI
FL767061300Medicaid