Provider Demographics
NPI:1902298532
Name:FORE, KIMBERLY WAIS (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:WAIS
Last Name:FORE
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 1:3027 SAN DIEGO RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3691
Mailing Address - Country:US
Mailing Address - Phone:904-303-4215
Mailing Address - Fax:904-348-2818
Practice Address - Street 1:3027 SAN DIEGO RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3691
Practice Address - Country:US
Practice Address - Phone:904-303-4215
Practice Address - Fax:904-346-5199
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW138821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical