Healthcare Provider Details

I. General information

NPI: 1679896120
Provider Name (Legal Business Name): BRENDA BAMBINO KNIERIM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2010
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233A MERCHANTS CIR STE 100
HAMPSTEAD NC
28443-5419
US

IV. Provider business mailing address

108 CIRCLE DR
HAMPSTEAD NC
28443-2108
US

V. Phone/Fax

Practice location:
  • Phone: 910-297-7720
  • Fax: 883-643-0176
Mailing address:
  • Phone: 910-297-7720
  • Fax: 833-643-0176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC006712
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: