=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689487472
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY W MIDDLEBROOKS MSW, LCSWA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2025
-----------------------------------------------------
Last Update Date | 01/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 S MAIN ST
-----------------------------------------------------
City | KANNAPOLIS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28081-4915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-269-8773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4463 BRAVERY PL SW
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28027-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-224-6778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | P021442
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------