Provider Demographics
NPI:1902444946
Name:KIMBROUGH, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 WINANS AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07205-1448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 WINANS AVE
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07205-1448
Practice Address - Country:US
Practice Address - Phone:908-868-7784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-19
Last Update Date:2023-03-09
Deactivation Date:2022-05-25
Deactivation Code:
Reactivation Date:2023-03-09
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06355600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
44SL06355600OtherLSW