Basic Information
| Provider Information | |||||||||
| NPI: | 1518925262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARSON | ||||||||
| FirstName: | KIMI | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 KINGS HIGHWAY CUTOFF | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068245340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033331133 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 75 KINGS HIGHWAY CUTOFF | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068245340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033331133 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 08/01/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 002599 | CT | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | 002599 | CT | N | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 060002599CT01 | 01 | CT | ANTHEM BLUE CROSS AND BLU | OTHER | 004248218 | 05 | CT | MEDICAID |