Provider Demographics
NPI:1013321090
Name:PEREZ, KIMM MARIE (PHD, LPA, LPC- S)
Entity Type:Individual
Prefix:DR
First Name:KIMM
Middle Name:MARIE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:PHD, LPA, LPC- S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11971 N GRAND PKWY E STE 200
Mailing Address - Street 2:#207
Mailing Address - City:NEW CANEY
Mailing Address - State:TX
Mailing Address - Zip Code:77357-1827
Mailing Address - Country:US
Mailing Address - Phone:346-471-5200
Mailing Address - Fax:346-474-0990
Practice Address - Street 1:11971 N GRAND PKWY E STE 200
Practice Address - Street 2:
Practice Address - City:NEW CANEY
Practice Address - State:TX
Practice Address - Zip Code:77357-1828
Practice Address - Country:US
Practice Address - Phone:346-471-5200
Practice Address - Fax:346-474-0990
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39232103TB0200X
TX64721101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX336059606Medicaid