Provider Demographics
NPI:1962918185
Name:KIMMEL, CHARLOTTE M (PHD)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:M
Last Name:KIMMEL
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:PO BOX 1478
Mailing Address - Street 2:
Mailing Address - City:MEXIA
Mailing Address - State:TX
Mailing Address - Zip Code:76667-1478
Mailing Address - Country:US
Mailing Address - Phone:903-390-2200
Mailing Address - Fax:
Practice Address - Street 1:2000 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-2510
Practice Address - Country:US
Practice Address - Phone:903-390-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23853103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Single Specialty