Provider Demographics
NPI:1295725893
Name:BRAYTON, KIMBERLY JOY (PHD, JD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOY
Last Name:BRAYTON
Suffix:
Gender:F
Credentials:PHD, JD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JOY
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:92 BAY ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-3031
Mailing Address - Country:US
Mailing Address - Phone:518-792-9100
Mailing Address - Fax:518-480-3189
Practice Address - Street 1:92 BAY ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3031
Practice Address - Country:US
Practice Address - Phone:518-480-3188
Practice Address - Fax:518-480-3189
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016568103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02694246Medicaid
NYIA0861Medicare ID - Type Unspecified