Provider Demographics
NPI:1073710307
Name:MOLDT, KIMBERLY QUEEN (MA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:QUEEN
Last Name:MOLDT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 COVE CAY DR APT 601
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-1328
Mailing Address - Country:US
Mailing Address - Phone:727-492-3872
Mailing Address - Fax:
Practice Address - Street 1:12600 BELCHER RD S UNIT 106F
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-1643
Practice Address - Country:US
Practice Address - Phone:727-492-3872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8213101YM0800X
WVLPC1452101YP2500X
FLMT2124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist