Provider Demographics
NPI:1528114824
Name:KICK, KIMBERLY A (MSW, LCSW, PHD)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:A
Last Name:KICK
Suffix:
Gender:F
Credentials:MSW, LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-1913
Mailing Address - Country:US
Mailing Address - Phone:847-400-6204
Mailing Address - Fax:847-327-1592
Practice Address - Street 1:709 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1913
Practice Address - Country:US
Practice Address - Phone:847-400-6204
Practice Address - Fax:847-327-1592
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0051071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL 1548Medicare PIN