Provider Demographics
NPI:1487990909
Name:STEPHENS, KIMBERLY S (MS, LSW, LICDC, LPC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:MS, LSW, LICDC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1059 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1433
Mailing Address - Country:US
Mailing Address - Phone:937-335-4543
Mailing Address - Fax:937-339-8371
Practice Address - Street 1:1059 N MARKET ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1433
Practice Address - Country:US
Practice Address - Phone:937-335-4543
Practice Address - Fax:937-339-8371
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0005671101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2901051Medicaid