Provider Demographics
NPI:1154418903
Name:TATE, KIMBERLY SHAFFER (PSYD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:SHAFFER
Last Name:TATE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41158
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45441-0158
Mailing Address - Country:US
Mailing Address - Phone:937-435-8864
Mailing Address - Fax:937-435-8264
Practice Address - Street 1:35 IRON GATE PARK DR.
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-0000
Practice Address - Country:US
Practice Address - Phone:937-435-8864
Practice Address - Fax:937-435-8264
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4664103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH028545000OtherMAGELLAN PIN
OH22000000356767OtherANTHEM PIN
OH172428110968OtherHUMANA PIN
OH281859OtherVALUE OPTIONS
OHS11267Medicare UPIN
OH172428110968OtherHUMANA PIN