Provider Demographics
NPI:1306283387
Name:WIMBERLY, NATALIE CHARISSE (PSYD)
Entity type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:CHARISSE
Last Name:WIMBERLY
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 1:490 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-1513
Mailing Address - Country:US
Mailing Address - Phone:518-458-2314
Mailing Address - Fax:518-446-9960
Practice Address - Street 1:490 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-1513
Practice Address - Country:US
Practice Address - Phone:518-458-2314
Practice Address - Fax:518-446-9960
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYP88750103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical