Provider Demographics
NPI:1780565317
Name:GIFFORD, KIMMER
Entity type:Individual
Prefix:
First Name:KIMMER
Middle Name:
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 WALL ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-4809
Mailing Address - Country:US
Mailing Address - Phone:845-943-3519
Mailing Address - Fax:888-888-8888
Practice Address - Street 1:67 WALL ST
Practice Address - Street 2:KINGSTON NY 12401
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-4809
Practice Address - Country:US
Practice Address - Phone:845-943-3519
Practice Address - Fax:888-888-8888
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0805851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical