Provider Demographics
NPI:1720332836
Name:WURST, KIMBERLEE A (PCC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLEE
Middle Name:A
Last Name:WURST
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6636 TAVENSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-7331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3095 KETTERING BLVD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1983
Practice Address - Country:US
Practice Address - Phone:937-293-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0008478101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor