Provider Demographics
NPI:1558713164
Name:KNICKERBOCKER, KIMBERLY (MSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 ROLLING HILLS LN APT 2
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-4760
Mailing Address - Country:US
Mailing Address - Phone:810-667-0500
Mailing Address - Fax:810-664-8728
Practice Address - Street 1:1570 SUNCREST DR
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1154
Practice Address - Country:US
Practice Address - Phone:810-667-0500
Practice Address - Fax:810-664-8728
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 1041C0700X
MI68011012051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker