Healthcare Provider Details

I. General information

NPI: 1699116228
Provider Name (Legal Business Name): KATHERINE DAWN GIMMESTAD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 S WASHINGTON AVE
LANSING MI
48910-0828
US

IV. Provider business mailing address

2025 S WASHINGTON AVE
LANSING MI
48910-0828
US

V. Phone/Fax

Practice location:
  • Phone: 517-267-3925
  • Fax:
Mailing address:
  • Phone: 816-305-1659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015590
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: