Provider Demographics
NPI:1952859647
Name:TUCKER TREMBLAY, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:TUCKER TREMBLAY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 WALTHAM ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-8033
Mailing Address - Country:US
Mailing Address - Phone:781-761-5148
Mailing Address - Fax:781-860-0589
Practice Address - Street 1:687 HIGHLAND AVE STE 17
Practice Address - Street 2:
Practice Address - City:NEEDHAM HEIGHTS
Practice Address - State:MA
Practice Address - Zip Code:02494-2232
Practice Address - Country:US
Practice Address - Phone:800-455-8726
Practice Address - Fax:781-860-0589
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPSY10001159103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303287OtherMBHP
MA1303287Medicaid
MA042611055OtherTAX ID
MA0000023532OtherBMC
MA1004745OtherNHP
MA99618201OtherNETWORK HEALTH
MAM18633OtherBCBS
MA042611055OtherTAX ID