Provider Demographics
NPI:1700485927
Name:GORE, KIMBERLY WAINE (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:WAINE
Last Name:GORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8435 TAVERNS LN
Mailing Address - Street 2:
Mailing Address - City:TOANO
Mailing Address - State:VA
Mailing Address - Zip Code:23168-8000
Mailing Address - Country:US
Mailing Address - Phone:757-218-5133
Mailing Address - Fax:
Practice Address - Street 1:1651 MERRIMAC TRL BLDG 1
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5624
Practice Address - Country:US
Practice Address - Phone:757-220-3200
Practice Address - Fax:757-253-4118
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040123851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical