Provider Demographics
NPI:1700910304
Name:LANGSTON, KIMBERLY RENEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:RENEE
Last Name:LANGSTON
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 1:2910 W 98TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2618
Mailing Address - Country:US
Mailing Address - Phone:773-439-0984
Mailing Address - Fax:
Practice Address - Street 1:10725 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-3217
Practice Address - Country:US
Practice Address - Phone:773-439-0984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL 149011122103T00000X
IL1490111221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist