Healthcare Provider Details

I. General information

NPI: 1790166593
Provider Name (Legal Business Name): KIMBERLY SCOTT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 BROOKS ST
WAKE FOREST NC
27587-2757
US

IV. Provider business mailing address

112 BROOKS ST
WAKE FOREST NC
27587-2757
US

V. Phone/Fax

Practice location:
  • Phone: 919-324-7361
  • Fax:
Mailing address:
  • Phone: 919-324-7361
  • Fax: 919-640-1901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC004666
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6002801
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: KIMBERLY SCOTT
Title or Position: DIRECTOR
Credential: LCSW
Phone: 919-414-3452