Provider Demographics
NPI:1922493535
Name:ANZEK, KIMBERLY E (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:E
Last Name:ANZEK
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 1:330 N MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4459
Mailing Address - Country:US
Mailing Address - Phone:937-813-6240
Mailing Address - Fax:937-619-8202
Practice Address - Street 1:330 N MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4459
Practice Address - Country:US
Practice Address - Phone:937-813-6240
Practice Address - Fax:937-619-8202
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7288103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0315928Medicaid