Provider Demographics
NPI:1932394046
Name:BROKAW, KIMBER ANN (LISW)
Entity Type:Individual
Prefix:MRS
First Name:KIMBER
Middle Name:ANN
Last Name:BROKAW
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-2925
Mailing Address - Country:US
Mailing Address - Phone:309-269-8810
Mailing Address - Fax:
Practice Address - Street 1:1035 LINCOLN RD
Practice Address - Street 2:SUITE 202
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-4198
Practice Address - Country:US
Practice Address - Phone:563-424-7137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2015-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04505104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker