Healthcare Provider Details

I. General information

NPI: 1013571181
Provider Name (Legal Business Name): KIMBERLY LOCKWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 05/03/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 CROSS VILLAGE DRIVE
MIAMISBURG OH
45342
US

IV. Provider business mailing address

2325 CROSS VILLAGE DRIVE
MIAMISBURG OH
45342
US

V. Phone/Fax

Practice location:
  • Phone: 937-829-3272
  • Fax:
Mailing address:
  • Phone: 937-829-3272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.2102429-SUPV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPP-000217274
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: