Healthcare Provider Details

I. General information

NPI: 1528326295
Provider Name (Legal Business Name): KIMBERLY HULTIN-AMIDEI LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PARK AVE
OKLAHOMA CITY OK
73102-7209
US

IV. Provider business mailing address

PO BOX 746878
ATLANTA GA
30374-6878
US

V. Phone/Fax

Practice location:
  • Phone: 323-205-7088
  • Fax: 833-419-0181
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10562
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7912
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06418500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: