Provider Demographics
NPI:1922074343
Name:DANIELS, KIMBERLY M (PSY D)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:DANIELS
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:682 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-4238
Mailing Address - Country:US
Mailing Address - Phone:860-231-2227
Mailing Address - Fax:860-231-2227
Practice Address - Street 1:682 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-4238
Practice Address - Country:US
Practice Address - Phone:860-231-2227
Practice Address - Fax:860-231-2227
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-25
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002380103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT680001473Medicare ID - Type Unspecified