Provider Demographics
NPI:1003887696
Name:KING, KIMBERLIE (PHD)
Entity Type:Individual
Prefix:
First Name:KIMBERLIE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2364 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1440
Mailing Address - Country:US
Mailing Address - Phone:617-332-2047
Mailing Address - Fax:617-332-7341
Practice Address - Street 1:2364 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1440
Practice Address - Country:US
Practice Address - Phone:617-332-2047
Practice Address - Fax:617-332-7341
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7561103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06005OtherBLUE CROSS BLUE SHIELD
MAW06005OtherBLUE CROSS BLUE SHIELD
P24183Medicare UPIN