MEDICARE: KIMBERLY BACK LISW-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	LICDC.161918	OH
2	1041C0700X	Clinical Social Worker	I.1451413	OH

General Provider Information

NPI Number	:	1578923181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY BACK LISW-S

Provider Business Mailing Address
First Line	:	100 CROWNE POINT PL
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45241-5427
Country	:	US
Telephone Number	:	513-743-7628
Fax Number	:

Provider Business Practice Location Address
First Line	:	6570 SOSNA DR STE 2
Second Line	:
City	:	FAIRFIELD
State	:	OH
Zip	:	45014-2222
Country	:	US
Telephone Number	:	513-942-4673
Fax Number	:	135-737-1107

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2016
Last Update Date	:	10/30/2023

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Directions to “ KIMBERLY BACK LISW-S” Practice Location

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