Provider Demographics
NPI:1053413229
Name:KIMBALL, WILLIAM HUMPHREY (PHD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:HUMPHREY
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9301
Mailing Address - Country:US
Mailing Address - Phone:315-779-9492
Mailing Address - Fax:
Practice Address - Street 1:1502 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9301
Practice Address - Country:US
Practice Address - Phone:315-779-9492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006662103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC5286Medicare ID - Type Unspecified