Healthcare Provider Details

I. General information

NPI: 1851383889
Provider Name (Legal Business Name): KIM CLARISSA DALLAS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM CLARISSA WEEKS LMSW

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 GOLDEN HILL LN
KINGSTON NY
12401-6441
US

IV. Provider business mailing address

239 GOLDEN HILL LN
KINGSTON NY
12401-6441
US

V. Phone/Fax

Practice location:
  • Phone: 845-340-4135
  • Fax: 845-340-4094
Mailing address:
  • Phone: 845-340-4125
  • Fax: 845-340-4094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06207700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number073220
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: