Provider Demographics
NPI:1801989140
Name:GEARHART, KIM RUSSELL (LCSW - R)
Entity type:Individual
Prefix:MR
First Name:KIM
Middle Name:RUSSELL
Last Name:GEARHART
Suffix:
Gender:M
Credentials:LCSW - R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9863 MORGAN RD
Mailing Address - Street 2:
Mailing Address - City:MARCY
Mailing Address - State:NY
Mailing Address - Zip Code:13403-2534
Mailing Address - Country:US
Mailing Address - Phone:315-732-9962
Mailing Address - Fax:
Practice Address - Street 1:7325 STATE ROUTE 5
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-3435
Practice Address - Country:US
Practice Address - Phone:315-859-1973
Practice Address - Fax:315-859-1979
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR042229-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health