Provider Demographics
NPI:1871941690
Name:KIMBERLY, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:KIMBERLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 WILSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:SC
Mailing Address - Zip Code:29369-9151
Mailing Address - Country:US
Mailing Address - Phone:864-574-6145
Mailing Address - Fax:
Practice Address - Street 1:115 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-9769
Practice Address - Country:US
Practice Address - Phone:864-439-0259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YP2500X101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional