Provider Demographics
NPI:1740846310
Name:FRY, KIMBERLY GOULD (LMFT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GOULD
Last Name:FRY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6104 TOSCANA AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78724-6249
Mailing Address - Country:US
Mailing Address - Phone:512-387-1398
Mailing Address - Fax:
Practice Address - Street 1:601 FARLEY DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-3114
Practice Address - Country:US
Practice Address - Phone:704-975-8613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-19
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
202865106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist