Healthcare Provider Details

I. General information

NPI: 1154690055
Provider Name (Legal Business Name): KIMBERLY RENEE ZUCKERMAN LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 RIDGLAND RD SUITE 1
COCKEYSVILLE MD
21030-2715
US

IV. Provider business mailing address

1006 BOSLEY RD
COCKEYSVILLE MD
21030-3114
US

V. Phone/Fax

Practice location:
  • Phone: 410-628-6120
  • Fax: 410-628-9825
Mailing address:
  • Phone: 443-527-2442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLG17568
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: