Provider Demographics
NPI:1972148773
Name:ALTOBELLI, KIMBERLY (EDS)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ALTOBELLI
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 BONNIE BRAE AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:OH
Mailing Address - Zip Code:44446-3803
Mailing Address - Country:US
Mailing Address - Phone:330-883-8766
Mailing Address - Fax:
Practice Address - Street 1:7320 N PALMYRA RD
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9709
Practice Address - Country:US
Practice Address - Phone:330-533-8755
Practice Address - Fax:330-533-8777
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3206762103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOH3206762Medicaid