Provider Demographics
NPI:1144116476
Name:BROTHERS, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BROTHERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CUE CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-6524
Mailing Address - Country:US
Mailing Address - Phone:631-291-3724
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD COUNTRY RD STE C103N
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5156
Practice Address - Country:US
Practice Address - Phone:631-291-3724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1245450182103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool