Provider Demographics
NPI:1356087613
Name:TRICKETT, KIMBERLY MICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:TRICKETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:TRICKETT
Other - Last Name:BUSHLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2603 LASALLE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-1146
Mailing Address - Country:US
Mailing Address - Phone:817-896-2582
Mailing Address - Fax:
Practice Address - Street 1:2603 LASALLE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-1146
Practice Address - Country:US
Practice Address - Phone:817-896-2582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX646211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical