Provider Demographics
NPI:1992418495
Name:WOODMAN, KIMBERLY (PHD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WOODMAN
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 1:2103 E WASHINGTON ST STE 4B
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4362
Mailing Address - Country:US
Mailing Address - Phone:309-706-1028
Mailing Address - Fax:
Practice Address - Street 1:2103 E WASHINGTON ST STE 4B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4362
Practice Address - Country:US
Practice Address - Phone:309-304-3047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-29
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007507103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty