Basic Information
| Provider Information | |||||||||
| NPI: | 1043408636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CULBREATH | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MSW, LLMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MELTON | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 28000 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480922468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867530405 | ||||||||
| FaxNumber: | 5867530404 | ||||||||
| Practice Location | |||||||||
| Address1: | 4777 E OUTER DR | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482343241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133695000 | ||||||||
| FaxNumber: | 3133695545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 12/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801091111 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.