Healthcare Provider Details

I. General information

NPI: 1417868274
Provider Name (Legal Business Name): MINDY MICHELLE KIBBEY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2026
Last Update Date: 09/12/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 SUMMIT AVE
PROVIDENCE RI
02906-2853
US

IV. Provider business mailing address

164 SUMMIT AVE
PROVIDENCE RI
02906-2853
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-4300
  • Fax: 401-793-4312
Mailing address:
  • Phone: 904-347-4881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS02484
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: