Provider Demographics
NPI:1932365343
Name:PATRICK, KIMBERLI DAWN (MED, LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLI
Middle Name:DAWN
Last Name:PATRICK
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1689
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-0043
Mailing Address - Country:US
Mailing Address - Phone:706-782-0717
Mailing Address - Fax:706-782-5266
Practice Address - Street 1:44 COTTONWOOD ST.
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525
Practice Address - Country:US
Practice Address - Phone:706-782-0717
Practice Address - Fax:706-782-5266
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC4008101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA514597267AMedicaid