Provider Demographics
NPI:1245669738
Name:FEZELL, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FEZELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:CLUTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4950 W 23RD ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-5802
Mailing Address - Country:US
Mailing Address - Phone:814-459-2755
Mailing Address - Fax:
Practice Address - Street 1:4950 W 23RD ST
Practice Address - Street 2:SUITE 1
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-5802
Practice Address - Country:US
Practice Address - Phone:814-459-2755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007134101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional