Provider Demographics
NPI:1104267228
Name:KIMBREW, BONITA CROOM (LCSW)
Entity type:Individual
Prefix:MS
First Name:BONITA
Middle Name:CROOM
Last Name:KIMBREW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 GREENWELL DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1731
Mailing Address - Country:US
Mailing Address - Phone:757-766-1711
Mailing Address - Fax:
Practice Address - Street 1:120 GREENWELL DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1731
Practice Address - Country:US
Practice Address - Phone:757-766-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040041471041C0700X
VAPPS3377051041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool