Basic Information
| Provider Information | |||||||||
| NPI: | 1629378955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSBORNE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | JILL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | EDS, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1269 PARKER RD SE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300945957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042340546 | ||||||||
| FaxNumber: | 7707619070 | ||||||||
| Practice Location | |||||||||
| Address1: | 1269 PARKER RD SE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300945957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042340546 | ||||||||
| FaxNumber: | 7707619070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2010 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC006170 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 003112503A | 05 | GA | MEDICAID | 003188998A | 05 | GA | MEDICAID | 003112500A | 05 | GA | MEDICAID |