Provider Demographics
NPI:1750417952
Name:ROSER-KEDWARD, KIM CHRISTINE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:CHRISTINE
Last Name:ROSER-KEDWARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:CHRISTINE
Other - Last Name:ROSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 16597
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92176-6441
Mailing Address - Country:US
Mailing Address - Phone:619-379-7450
Mailing Address - Fax:
Practice Address - Street 1:4075 PARK BLVD
Practice Address - Street 2:STE 102-212
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2670
Practice Address - Country:US
Practice Address - Phone:619-379-7450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS224051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW22405AMedicare PIN