Basic Information
| Provider Information | |||||||||
| NPI: | 1679881726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLETTE | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1298 BAY DALE DR STE 211 | ||||||||
| Address2: | |||||||||
| City: | ARNOLD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210122815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109194904 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1298 BAY DALE DR STE 211 | ||||||||
| Address2: | |||||||||
| City: | ARNOLD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210122815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109194904 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2010 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.