Provider Demographics
NPI:1407141369
Name:HINTZ, KIMBERLY CHARLOTTE (MA, ITDS)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:CHARLOTTE
Last Name:HINTZ
Suffix:
Gender:F
Credentials:MA, ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 BROOKCREST CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4749
Mailing Address - Country:US
Mailing Address - Phone:321-986-7184
Mailing Address - Fax:
Practice Address - Street 1:6230 EDISON ST
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-8833
Practice Address - Country:US
Practice Address - Phone:321-431-8345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 222Q00000X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health