Provider Demographics
NPI:1255649398
Name:CARNEGIE BRISCOE, KIMBERLY (PHD/DSW)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:CARNEGIE BRISCOE
Suffix:
Gender:F
Credentials:PHD/DSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5612 E 117TH AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-8681
Mailing Address - Country:US
Mailing Address - Phone:218-814-2793
Mailing Address - Fax:
Practice Address - Street 1:5612 E 117TH AVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307
Practice Address - Country:US
Practice Address - Phone:219-814-2793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103T00000X, 103TA0700X, 170100000X
IN103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics