Provider Demographics
NPI:1447833710
Name:AVANCE, KIMBERLY J (MSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:AVANCE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:J
Other - Last Name:AVANCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:226 E WOODSIDE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-1116
Mailing Address - Country:US
Mailing Address - Phone:269-240-7711
Mailing Address - Fax:
Practice Address - Street 1:226 E WOODSIDE ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-1116
Practice Address - Country:US
Practice Address - Phone:269-240-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010823321041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool