Healthcare Provider Details

I. General information

NPI: 1861034381
Provider Name (Legal Business Name): KIMBERLY MAE KIRKLIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2019
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21998 AUDRAIN ROAD 322
MEXICO MO
65265-5860
US

IV. Provider business mailing address

21998 AUDRAIN ROAD 322
MEXICO MO
65265-5860
US

V. Phone/Fax

Practice location:
  • Phone: 660-676-7599
  • Fax:
Mailing address:
  • Phone: 660-676-7599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2019015418
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2021029435
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: