Provider Demographics
NPI:1396504403
Name:SIDLAUSKAS, KIMBERLY R (LLMSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:SIDLAUSKAS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:R
Other - Last Name:RICHARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5970 AVALON DR APT 117
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-7764
Mailing Address - Country:US
Mailing Address - Phone:616-581-0776
Mailing Address - Fax:
Practice Address - Street 1:5970 AVALON DR APT 117
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-7764
Practice Address - Country:US
Practice Address - Phone:616-581-0776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511177281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical