Basic Information
Provider Information | |||||||||
NPI: | 1578172649 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DESCHAMPS | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW-C, MSED | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 105 2ND AVE | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN PARK | ||||||||
State: | MD | ||||||||
PostalCode: | 212252712 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6672033485 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 407 CENTRAL AVE | ||||||||
Address2: |   | ||||||||
City: | REISTERSTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 211361854 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105175400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2020 | ||||||||
LastUpdateDate: | 07/24/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/24/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 26143 | MD | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.