1992053771 NPI number — PROF. KIMBERLY KAYE ASNER-SELF ED.D., NCC, LCPC

Table of content: PROF. KIMBERLY KAYE ASNER-SELF ED.D., NCC, LCPC (NPI 1992053771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992053771 NPI number — PROF. KIMBERLY KAYE ASNER-SELF ED.D., NCC, LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ASNER-SELF
Provider First Name:
KIMBERLY
Provider Middle Name:
KAYE
Provider Name Prefix Text:
PROF.
Provider Name Suffix Text:
Provider Credential Text:
ED.D., NCC, LCPC
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:
1992053771
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 WHAM DR
Provider Second Line Business Mailing Address:
MAIL CODE 4618
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62901-4313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-453-2311
Provider Business Mailing Address Fax Number:
618-453-7110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 LOU ANN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERRIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62948-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-988-1330
Provider Business Practice Location Address Fax Number:
618-988-8321
Provider Enumeration Date:
08/27/2012

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: 101YP2500X , with the licence number:  180.004440 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 180.004440 . This is a "LICENSED CLINICAL PROFESSION COUNSELOR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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