Provider Demographics
NPI:1306877345
Name:HAGA, KIMBERLY SUE (PHD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:HAGA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 VIA CARRARA
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-3792
Mailing Address - Country:US
Mailing Address - Phone:850-291-4138
Mailing Address - Fax:866-631-8054
Practice Address - Street 1:13 VIA CARRARA
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-3792
Practice Address - Country:US
Practice Address - Phone:850-291-4138
Practice Address - Fax:866-631-8054
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5717103TB0200X, 103TC2200X, 103TC0700X, 103TB0200X
IN20041544A103TB0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPY5717OtherLICENSE NO