Provider Demographics
NPI:1124047535
Name:HAYES, KIMBERLY RUSSELL (LCSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RUSSELL
Last Name:HAYES
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 1:5509 TRAIL RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-8590
Mailing Address - Country:US
Mailing Address - Phone:704-574-7808
Mailing Address - Fax:704-536-6030
Practice Address - Street 1:314 N HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-2108
Practice Address - Country:US
Practice Address - Phone:704-567-8690
Practice Address - Fax:704-536-6030
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0053591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCE4158-B0775OtherMEDCOST
NC14248OtherBCBS
NC6106457Medicaid
NC6106457Medicaid