Provider Demographics
NPI:1063884211
Name:LODGE, KYMBERLY
Entity type:Individual
Prefix:
First Name:KYMBERLY
Middle Name:
Last Name:LODGE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 WALDEN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225
Mailing Address - Country:US
Mailing Address - Phone:716-895-6700
Mailing Address - Fax:716-895-0436
Practice Address - Street 1:1526 WALDEN AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225
Practice Address - Country:US
Practice Address - Phone:716-895-6700
Practice Address - Fax:716-895-0436
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OHI.2506547104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker