Provider Demographics
NPI:1730869991
Name:SAMUELSON, KIMBERLY (LMSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 NEW HAMPSHIRE ST APT 406
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2781
Mailing Address - Country:US
Mailing Address - Phone:585-710-5500
Mailing Address - Fax:
Practice Address - Street 1:888 NEW HAMPSHIRE ST APT 406
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2781
Practice Address - Country:US
Practice Address - Phone:585-710-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113211-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker