Healthcare Provider Details

I. General information

NPI: 1306206008
Provider Name (Legal Business Name): KIMBERLY MOUSTOUKKIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY ANN BIELFELDT

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 SUSAN DR STE C
NORMAL IL
61761-6285
US

IV. Provider business mailing address

321 SUSAN DR STE C
NORMAL IL
61761-6285
US

V. Phone/Fax

Practice location:
  • Phone: 309-455-5703
  • Fax:
Mailing address:
  • Phone: 309-455-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: