Basic Information
| Provider Information | |||||||||
| NPI: | 1427032085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WRIGHT | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 S TREATY RD | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743545327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185401511 | ||||||||
| FaxNumber: | 9185427374 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S TREATY RD | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743545327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185401511 | ||||||||
| FaxNumber: | 9185427374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 10/22/2018 | ||||||||
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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 | 1041C0700X | 2000148148 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 755752706 | 05 | MO | MEDICAID | 495752701 | 05 | MO | MEDICAID |