=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124047535
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY RUSSELL HAYES LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 02/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 314 N HIGHLAND ST
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28052-2108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-567-8690
-----------------------------------------------------
Fax | 704-536-6030
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5509 TRAIL RIDGE CT
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28056-8590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-574-7808
-----------------------------------------------------
Fax | 704-536-6030
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C005359
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------