Healthcare Provider Details

I. General information

NPI: 1447833710
Provider Name (Legal Business Name): KIMBERLY J AVANCE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY J AVANCE MSW

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 E WOODSIDE ST
SOUTH BEND IN
46614-1116
US

IV. Provider business mailing address

226 E WOODSIDE ST
SOUTH BEND IN
46614-1116
US

V. Phone/Fax

Practice location:
  • Phone: 269-240-7711
  • Fax:
Mailing address:
  • Phone: 269-240-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6801082332
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: