Provider Demographics
NPI:1972931350
Name:ALTICK, KIMBERLY (LISW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ALTICK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 HOPELAND ST BLDG A
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3420
Mailing Address - Country:US
Mailing Address - Phone:937-367-4830
Mailing Address - Fax:
Practice Address - Street 1:257 HOPELAND ST BLDG A
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3420
Practice Address - Country:US
Practice Address - Phone:937-245-6119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.17004461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical