Provider Demographics
NPI:1134594542
Name:TREVITHICK, KIMBERLY (MED)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:TREVITHICK
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 1:616 PEEBLES ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15221-3213
Mailing Address - Country:US
Mailing Address - Phone:610-357-9887
Mailing Address - Fax:
Practice Address - Street 1:5648 FRIENDSHIP AVE
Practice Address - Street 2:GLADE RUN LUTHERAN SERVICES
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15206-3610
Practice Address - Country:US
Practice Address - Phone:610-357-9887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1967601101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool