Provider Demographics
NPI:1477002889
Name:KIMBERLY GEREDA PSYCHOTHERAPY & SELF-CARE
Entity Type:Organization
Organization Name:KIMBERLY GEREDA PSYCHOTHERAPY & SELF-CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF PRACTICE
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GEREDA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-525-4272
Mailing Address - Street 1:59 ELM ST
Mailing Address - Street 2:SUITE #500
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2047
Mailing Address - Country:US
Mailing Address - Phone:203-525-4272
Mailing Address - Fax:
Practice Address - Street 1:59 ELM ST
Practice Address - Street 2:SUITE #500
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2047
Practice Address - Country:US
Practice Address - Phone:203-525-4272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0076761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008067075Medicaid