Provider Demographics
NPI:1992056824
Name:HENDRICKSON, KIMBERLY S (MSW)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:S
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18341 US HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:LANSE
Mailing Address - State:MI
Mailing Address - Zip Code:49946-8024
Mailing Address - Country:US
Mailing Address - Phone:906-524-3355
Mailing Address - Fax:906-524-3411
Practice Address - Street 1:18341 US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946-8024
Practice Address - Country:US
Practice Address - Phone:906-524-3355
Practice Address - Fax:906-524-3411
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801073221101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0960978OtherBCBS
MI1841555430OtherRHC MEDICAID NPI NUMBER
MI23-8646OtherRHC MEDICARE
MI1992056824Medicaid
MI6801073221OtherCLINICAL SOCIAL WORKER LICENSE NUMBER
MI0960978OtherBCBS