Provider Demographics
NPI:1780199950
Name:WIGHTON, KIMBERLY ELYSE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ELYSE
Last Name:WIGHTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 CARNATION DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-7012
Mailing Address - Country:US
Mailing Address - Phone:516-304-4105
Mailing Address - Fax:
Practice Address - Street 1:345 CARNATION DR
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-7012
Practice Address - Country:US
Practice Address - Phone:516-304-4105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
NY102352-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty