Provider Demographics
NPI:1306246210
Name:CLOUGH, KIMBERLY (LCSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CLOUGH
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 1:1121 JUDSON RD STE 182
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5199
Mailing Address - Country:US
Mailing Address - Phone:903-309-0960
Mailing Address - Fax:903-309-1630
Practice Address - Street 1:1010 TRISTAN LN
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-1862
Practice Address - Country:US
Practice Address - Phone:903-918-6574
Practice Address - Fax:903-704-0980
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX590131041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX373636501Medicaid