MEDICARE: KIMBERLY E CHURCH PSYD

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	103K00000X	Behavior Analyst	PY7577	FL
2	103TC0700X	Clinical Psychologist	PY7577	FL

General Provider Information

NPI Number	:	1215177795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY E CHURCH PSYD

Provider Business Mailing Address
First Line	:	22867 SOUTHSHORE DR
Second Line	:
City	:	LAND O LAKES
State	:	FL
Zip	:	34639-4755
Country	:	US
Telephone Number	:	813-468-3505
Fax Number	:

Provider Business Practice Location Address
First Line	:	308 E OAK AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33602-2344
Country	:	US
Telephone Number	:	813-810-8110
Fax Number	:

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

Provider Enumeration Date	:	02/24/2009
Last Update Date	:	02/24/2009

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