Provider Demographics
NPI:1699075242
Name:SHEA, KIMBERLY (LICSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3007
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98114-3007
Mailing Address - Country:US
Mailing Address - Phone:206-788-3616
Mailing Address - Fax:206-652-5216
Practice Address - Street 1:17018 15TH AVE NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155
Practice Address - Country:US
Practice Address - Phone:206-362-7282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61013326390200000X
WALW608083711041C0700X
WACL60165257101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional