Healthcare Provider Details

I. General information

NPI: 1093761900
Provider Name (Legal Business Name): KIMBERLY K CHARBONEAU LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

284 MAIN ST SUITE 320
SCHOHARIE NY
12157-2118
US

IV. Provider business mailing address

197 NORTHAMPTON RD
AMSTERDAM NY
12010-1726
US

V. Phone/Fax

Practice location:
  • Phone: 518-295-8336
  • Fax: 518-295-8724
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR044142
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: