Provider Demographics
NPI:1366741522
Name:PORE, KIMBERLY KAY (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KAY
Last Name:PORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:TX
Mailing Address - Zip Code:78934-2131
Mailing Address - Country:US
Mailing Address - Phone:979-732-6204
Mailing Address - Fax:979-732-5289
Practice Address - Street 1:1460 WALNUT ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:TX
Practice Address - Zip Code:78934-2131
Practice Address - Country:US
Practice Address - Phone:979-732-6204
Practice Address - Fax:979-732-5289
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-26
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX395091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical