Provider Demographics
NPI:1215177795
Name:CHURCH, KIMBERLY E (PSYD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:E
Last Name:CHURCH
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 1:22867 SOUTHSHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-4755
Mailing Address - Country:US
Mailing Address - Phone:813-468-3505
Mailing Address - Fax:
Practice Address - Street 1:308 E OAK AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-2344
Practice Address - Country:US
Practice Address - Phone:813-810-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7577103K00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst