Healthcare Provider Details

I. General information

NPI: 1598240053
Provider Name (Legal Business Name): KIMBERLY KOCAK MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 MAIN ST
COLUMBIA SC
29201-2817
US

IV. Provider business mailing address

1631 MAIN ST
COLUMBIA SC
29201-2817
US

V. Phone/Fax

Practice location:
  • Phone: 803-567-1217
  • Fax:
Mailing address:
  • Phone: 803-567-1217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14277
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: