Provider Demographics
NPI:1053078444
Name:PERSAUD, KIMBERLY M (DBA,MS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:PERSAUD
Suffix:
Gender:F
Credentials:DBA,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 ESSEX ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-4407
Mailing Address - Country:US
Mailing Address - Phone:646-725-6271
Mailing Address - Fax:
Practice Address - Street 1:115 E 23RD ST FL 9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4559
Practice Address - Country:US
Practice Address - Phone:347-600-9463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-21
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TB0200X, 103TA0400X, 103TC1900X, 103TC2200X, 103TF0000X, 103TP2701X, 251B00000X, 252Y00000X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYZJ84485VMedicaid