Provider Demographics
NPI:1962659607
Name:PSYCHOLOGICAL ASSESSMENT AND CONSULTING, PC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL ASSESSMENT AND CONSULTING, PC
Other - Org Name:WILLOW BRANCH COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMMERLING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:765-755-0052
Mailing Address - Street 1:1806 W ROYALE DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2243
Mailing Address - Country:US
Mailing Address - Phone:765-755-0052
Mailing Address - Fax:765-755-0052
Practice Address - Street 1:1806 W ROYALE DR
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2243
Practice Address - Country:US
Practice Address - Phone:765-755-0052
Practice Address - Fax:765-755-0052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-25
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041639A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200911770AMedicaid
IN11646258OtherCAQH
IN000000588248OtherANTHEM BC/BS PIN
IN11646258OtherCAQH