MEDICARE: DR. KATHERINE DAWN GIMMESTAD 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	6301015590	MI

General Provider Information

NPI Number	:	1699116228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHERINE DAWN GIMMESTAD PH.D.

Provider Business Mailing Address
First Line	:	2025 S WASHINGTON AVE
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48910-0828
Country	:	US
Telephone Number	:	816-305-1659
Fax Number	:

Provider Business Practice Location Address
First Line	:	2025 S WASHINGTON AVE
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48910-0828
Country	:	US
Telephone Number	:	517-267-3925
Fax Number	:

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

Provider Enumeration Date	:	07/11/2013
Last Update Date	:	09/25/2013

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