Healthcare Provider Details

I. General information

NPI: 1700485927
Provider Name (Legal Business Name): KIMBERLY WAINE GORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 MERRIMAC TRL BLDG 1
WILLIAMSBURG VA
23185-5624
US

IV. Provider business mailing address

8435 TAVERNS LN
TOANO VA
23168-8000
US

V. Phone/Fax

Practice location:
  • Phone: 757-220-3200
  • Fax: 757-253-4118
Mailing address:
  • Phone: 757-218-5133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904012385
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: