Provider Demographics
NPI:1720542202
Name:LANDRAU, KIMBERLY A (PHD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:LANDRAU
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 1:40 DEVEREUX ROAD
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:ME
Mailing Address - Zip Code:04667
Mailing Address - Country:US
Mailing Address - Phone:207-904-7589
Mailing Address - Fax:
Practice Address - Street 1:40 DEVEREUX ROAD
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:ME
Practice Address - Zip Code:04667
Practice Address - Country:US
Practice Address - Phone:207-904-7589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MEPS2443103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor