Provider Demographics
NPI:1801392642
Name:GEOHAGAN, KIMBERLY (MED)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GEOHAGAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1927 EF GRIFFIN RD
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-9721
Mailing Address - Country:US
Mailing Address - Phone:863-797-9261
Mailing Address - Fax:
Practice Address - Street 1:1927 EF GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-9721
Practice Address - Country:US
Practice Address - Phone:863-797-9261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty