Provider Demographics
NPI:1215044581
Name:PRADERAS, KIM (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:PRADERAS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W. 38TH ST.
Mailing Address - Street 2:#306
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6406
Mailing Address - Country:US
Mailing Address - Phone:512-458-2606
Mailing Address - Fax:512-828-7042
Practice Address - Street 1:1600 W. 38TH ST.
Practice Address - Street 2:#306
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6406
Practice Address - Country:US
Practice Address - Phone:512-458-2606
Practice Address - Fax:512-828-7042
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-3796103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00K74HMedicare ID - Type Unspecified