Basic Information
| Provider Information | |||||||||
| NPI: | 1114282811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHASE | ||||||||
| FirstName: | KIMBRA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 741 DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142092201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162181400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 560 W 3RD ST | ||||||||
| Address2: | SUITE 17 | ||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147014776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164849188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2012 | ||||||||
| LastUpdateDate: | 07/09/2012 | ||||||||
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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 | 00066294 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.