Provider Demographics
NPI:1518925262
Name:CARSON, KIMI (PHD)
Entity Type:Individual
Prefix:
First Name:KIMI
Middle Name:
Last Name:CARSON
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 1:75 KINGS HIGHWAY CUTOFF
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-5340
Mailing Address - Country:US
Mailing Address - Phone:203-333-1133
Mailing Address - Fax:
Practice Address - Street 1:75 KINGS HIGHWAY CUTOFF
Practice Address - Street 2:5TH FLOOR
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5340
Practice Address - Country:US
Practice Address - Phone:203-333-1133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002599103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060002599CT01OtherANTHEM BLUE CROSS AND BLU
CT004248218Medicaid
CT060002599CT01OtherANTHEM BLUE CROSS AND BLU
CTP00245270Medicare PIN