Provider Demographics
NPI:1225195126
Name:KIMMELMAN, STACEY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:KIMMELMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 COMMONWEALTH AVE
Mailing Address - Street 2:SUITE U3
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2707
Mailing Address - Country:US
Mailing Address - Phone:617-259-1895
Mailing Address - Fax:
Practice Address - Street 1:160 COMMONWEALTH AVE
Practice Address - Street 2:SUITE U3
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-2707
Practice Address - Country:US
Practice Address - Phone:617-259-1895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8199103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW51483Medicare ID - Type UnspecifiedCURRENT MEDICARE NUMBER