Healthcare Provider Details

I. General information

NPI: 1245535269
Provider Name (Legal Business Name): KIMBERLY PATRICE SPIVEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2011
Last Update Date: 01/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5113 MONROE ST
MATTESON IL
60443-3072
US

IV. Provider business mailing address

5113 MONROE ST
MATTESON IL
60443-3072
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-1292
  • Fax: 708-747-1292
Mailing address:
  • Phone: 708-747-1292
  • Fax: 708-747-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.013263
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: