Provider Demographics
NPI:1417174368
Name:DEFFEBACH, KIM (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:DEFFEBACH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-2533
Mailing Address - Country:US
Mailing Address - Phone:321-223-0147
Mailing Address - Fax:
Practice Address - Street 1:1101 RIVER RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32951-2533
Practice Address - Country:US
Practice Address - Phone:321-223-0147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 6195103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist