=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033499959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY SLADE PLCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2011
-----------------------------------------------------
Last Update Date | 08/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 232 GILMER ST SUITE 206
-----------------------------------------------------
City | REIDSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27320-3860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-347-7415
-----------------------------------------------------
Fax | 336-347-7419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 232 GILMER ST SUITE 206
-----------------------------------------------------
City | REIDSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27320-3860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-347-7415
-----------------------------------------------------
Fax | 336-347-7419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | P005551
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------