Provider Demographics
NPI:1578177796
Name:KIMMELMAN, CORINNE
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:
Last Name:KIMMELMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 HOLLANDALE LN
Mailing Address - Street 2:APT. G
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-5282
Mailing Address - Country:US
Mailing Address - Phone:631-678-5117
Mailing Address - Fax:
Practice Address - Street 1:2452 ROUTE 9
Practice Address - Street 2:SUITE 206
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020
Practice Address - Country:US
Practice Address - Phone:518-292-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYP107763101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program