Provider Demographics
NPI:1831579135
Name:KOLARIK, KIMBERLY ANN (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:KOLARIK
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 1:1816 PARKDALE DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-5463
Mailing Address - Country:US
Mailing Address - Phone:630-234-3685
Mailing Address - Fax:
Practice Address - Street 1:501 N DUNLAP AVE
Practice Address - Street 2:
Practice Address - City:SAVOY
Practice Address - State:IL
Practice Address - Zip Code:61874-8403
Practice Address - Country:US
Practice Address - Phone:217-693-6072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0079691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210732Medicare PIN