Provider Demographics
NPI:1568542587
Name:BOOKER, KIMBERLY W (PHD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:W
Last Name:BOOKER
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 1:601 WALNUT BEND DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 N LITTLE SCHOOL RD
Practice Address - Street 2:SUITE B
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-1900
Practice Address - Country:US
Practice Address - Phone:817-533-0823
Practice Address - Fax:817-391-1444
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33101103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194228601Medicaid