Provider Demographics
NPI:1356575476
Name:UNDERDUE, KIMBERLY SHAWN (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:SHAWN
Last Name:UNDERDUE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1071 LAUREL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-8432
Mailing Address - Country:US
Mailing Address - Phone:678-851-9509
Mailing Address - Fax:678-623-3748
Practice Address - Street 1:165 BURKE ST
Practice Address - Street 2:SUITE 109
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-3463
Practice Address - Country:US
Practice Address - Phone:770-389-9886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0043681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA315091169AMedicaid