Provider Demographics
NPI:1417044165
Name:HENDERSON-KJELLEN, KIMBERLY (PSYD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HENDERSON-KJELLEN
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 1:1097 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037-2241
Mailing Address - Country:US
Mailing Address - Phone:860-836-7553
Mailing Address - Fax:
Practice Address - Street 1:1097 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06037-2241
Practice Address - Country:US
Practice Address - Phone:860-836-7553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002808103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist