Provider Demographics
NPI:1093290678
Name:KONDERLA, KIMBERLY L (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:KONDERLA
Suffix:
Gender:
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 SE 29TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK ISLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28465-6005
Mailing Address - Country:US
Mailing Address - Phone:713-454-3870
Mailing Address - Fax:
Practice Address - Street 1:118 SE 29TH ST
Practice Address - Street 2:
Practice Address - City:OAK ISLAND
Practice Address - State:NC
Practice Address - Zip Code:28465-6005
Practice Address - Country:US
Practice Address - Phone:713-454-3870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0142771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical