Healthcare Provider Details

I. General information

NPI: 1427751882
Provider Name (Legal Business Name): KIMBERLY EVONNE HULETT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY EVONNE STEVENSON LCSW

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 07/13/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1736 W GORDON ST
VALDOSTA GA
31601-3017
US

IV. Provider business mailing address

2004 CAROLYN TER
VALDOSTA GA
31602-2102
US

V. Phone/Fax

Practice location:
  • Phone: 229-262-7198
  • Fax:
Mailing address:
  • Phone: 229-834-1315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8470
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: