=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275738718
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY S D'ANDREA PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2007
-----------------------------------------------------
Last Update Date | 07/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 517 PIERCE STREET
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-829-2250
-----------------------------------------------------
Fax | 570-344-6699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 THACKEKAY CLOSE
-----------------------------------------------------
City | MOOSIC
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-814-7994
-----------------------------------------------------
Fax | 570-344-6699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS016214
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------