MEDICARE: DR. WILLIAM HUMPHREY KIMBALL PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	006662	NY

General Provider Information

NPI Number	:	1053413229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM HUMPHREY KIMBALL PH.D.

Provider Business Mailing Address
First Line	:	1502 WASHINGTON ST
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-9301
Country	:	US
Telephone Number	:	315-779-9492
Fax Number	:

Provider Business Practice Location Address
First Line	:	1502 WASHINGTON ST
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-9301
Country	:	US
Telephone Number	:	315-779-9492
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	02/25/2013

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