Kimberly Shaffer Tate, PSY.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

4664 Issued in OH

Practice address

35 Iron Gate Park Dr.
Centerville, OH 45459-0000

Phone

(937) 435-8864

Fax

(937) 435-8264

NPI assigned

Oct 5, 2006

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 4

Medicare fee-for-service enrollment

Enrolled in OH

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Psychologist

Education

Other, 1986

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Southwestern Ohio Behavioral Health,LLC

  • Clinical Psychologist
  • Centerville, OH
  • NPI 1376631713
  Medicare reassignment NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160006400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183939200000",
    "number": "1154418903",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 41158",
            "city": "CENTERVILLE",
            "state": "OH",
            "postal_code": "454410158",
            "telephone_number": "937-435-8864",
            "fax_number": "937-435-8264"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "35 IRON GATE PARK DR.",
            "city": "CENTERVILLE",
            "state": "OH",
            "postal_code": "454590000",
            "telephone_number": "937-435-8864",
            "fax_number": "937-435-8264"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TATE",
        "first_name": "KIMBERLY",
        "middle_name": "SHAFFER",
        "name_prefix": "Dr.",
        "credential": "PSY.D.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-10-05",
        "last_updated": "2007-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "OH",
            "license": "4664",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MAGELLAN PIN",
            "identifier": "028545000",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM  PIN",
            "identifier": "22000000356767",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HUMANA PIN",
            "identifier": "172428110968",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VALUE OPTIONS",
            "identifier": "281859",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Clinical Psychologist in Centerville, OH
• Providers in Centerville, OH by specialty
• Clinical Psychologist in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.