Healthcare Provider Details

I. General information

NPI: 1366769838
Provider Name (Legal Business Name): KIM OLMEDO LCSW, CCM, CSW-G
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 04/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 SHADY HILL LN
ARLINGTON TX
76016-2125
US

IV. Provider business mailing address

5900 SHADY HILL LN
ARLINGTON TX
76016-2125
US

V. Phone/Fax

Practice location:
  • Phone: 817-996-5574
  • Fax:
Mailing address:
  • Phone: 817-996-5574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14363
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: