Provider Demographics
NPI:1053633974
Name:VANDALE, KIMBERLY GERISSE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:GERISSE
Last Name:VANDALE
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 1:116 MARKET ST
Mailing Address - Street 2:PERCEPTIONS COUNSELING SERVICES
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-5674
Mailing Address - Country:US
Mailing Address - Phone:586-465-4444
Mailing Address - Fax:586-783-2761
Practice Address - Street 1:116 MARKET ST
Practice Address - Street 2:PERCEPTIONS COUNSELING SERVICES
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-5674
Practice Address - Country:US
Practice Address - Phone:586-465-4444
Practice Address - Fax:586-783-2761
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014352103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist