Provider Demographics
NPI:1750316543
Name:KIMMEL, DOUGLAS C (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:C
Last Name:KIMMEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 CAPTAIN BILL ROAD
Mailing Address - Street 2:PO BOX 466
Mailing Address - City:HANCOCK
Mailing Address - State:ME
Mailing Address - Zip Code:04640-0466
Mailing Address - Country:US
Mailing Address - Phone:207-422-3686
Mailing Address - Fax:
Practice Address - Street 1:13 CAPTAIN BILL ROAD
Practice Address - Street 2:TAMARACK PLACE SUITE 2
Practice Address - City:HANCOCK
Practice Address - State:ME
Practice Address - Zip Code:04640-0466
Practice Address - Country:US
Practice Address - Phone:207-422-3686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME715103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM3349Medicare ID - Type Unspecified