Provider Demographics
NPI:1164555421
Name:HERNANDEZ, KIM-MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIM-MARIE
Middle Name:
Last Name:HERNANDEZ
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 1:6012 W WILLIAM CANNON DR STE B103
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1978
Mailing Address - Country:US
Mailing Address - Phone:512-633-2757
Mailing Address - Fax:
Practice Address - Street 1:6012 W WILLIAM CANNON DR STE B103
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1978
Practice Address - Country:US
Practice Address - Phone:512-633-2757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32190103T00000X
TX31471103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool