Provider Demographics
NPI:1811101926
Name:LEAVELL, KIMBERLY (MSW CSW)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:LEAVELL
Suffix:
Gender:F
Credentials:MSW CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31075 HUNTLEY SQUARE EAST
Mailing Address - Street 2:SUITE 824
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025
Mailing Address - Country:US
Mailing Address - Phone:248-723-3366
Mailing Address - Fax:248-723-3366
Practice Address - Street 1:31075 HUNTLEY SQUARE EAST
Practice Address - Street 2:SUITE 824
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025
Practice Address - Country:US
Practice Address - Phone:248-723-3366
Practice Address - Fax:248-723-3366
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010660691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON26440Medicare ID - Type Unspecified