Provider Demographics
NPI:1588295620
Name:SIWIK, KIMBERLY TUCKER (LPCC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:TUCKER
Last Name:SIWIK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 SHOREFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44215-9721
Mailing Address - Country:US
Mailing Address - Phone:330-612-0874
Mailing Address - Fax:
Practice Address - Street 1:140 WADSWORTH RD
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-9503
Practice Address - Country:US
Practice Address - Phone:330-667-0260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC2002234TRNE101Y00000X
OHE.2303516101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor