Provider Demographics
NPI:1518925262
Name:CARSON, KIMI (PHD)
Entity type:Individual
Prefix:
First Name:KIMI
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 24TH AVE NW STE 100
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6344
Mailing Address - Country:US
Mailing Address - Phone:405-321-0303
Mailing Address - Fax:
Practice Address - Street 1:1006 24TH AVE NW STE 100
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6344
Practice Address - Country:US
Practice Address - Phone:405-321-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1114103G00000X
CT002599103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060002599CT01OtherANTHEM BLUE CROSS AND BLU
CT004248218Medicaid
CT060002599CT01OtherANTHEM BLUE CROSS AND BLU
CTP00245270Medicare PIN