1114991320 NPI number — MRS. KIMBERLY BENTON-HERZBERG M.S.W

Table of content: MRS. KIMBERLY BENTON-HERZBERG M.S.W (NPI 1114991320)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114991320 NPI number — MRS. KIMBERLY BENTON-HERZBERG M.S.W

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENTON-HERZBERG
Provider First Name:
KIMBERLY
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S.W
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114991320
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 MEADOW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEVADA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50201-2208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-382-2004
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 HAYWARD AVE SUITE 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-290-1534
Provider Business Practice Location Address Fax Number:
319-865-3110
Provider Enumeration Date:
02/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  00593 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0058230 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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