Basic Information
| Provider Information | |||||||||
| NPI: | 1124047535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAYES | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5509 TRAIL RIDGE CT | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280568590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045747808 | ||||||||
| FaxNumber: | 7045366030 | ||||||||
| Practice Location | |||||||||
| Address1: | 314 N HIGHLAND ST | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280522108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045678690 | ||||||||
| FaxNumber: | 7045366030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 02/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C005359 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | E4158-B0775 | 01 | NC | MEDCOST | OTHER | 14248 | 01 | NC | BCBS | OTHER | 6106457 | 05 | NC | MEDICAID |