Basic Information
Provider Information
NPI: 1003007477
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ABDOW
FirstName: KIMBERLY
MiddleName: BETH
NamePrefix: MS.
NameSuffix:  
Credential: N.P.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 202 RUSSELL ST
Address2:  
City: WORCESTER
State: MA
PostalCode: 016092265
CountryCode: US
TelephoneNumber: 5087535554
FaxNumber:  
Practice Location
Address1: 435 SHREWSBURY ST
Address2:  
City: WORCESTER
State: MA
PostalCode: 016092265
CountryCode: US
TelephoneNumber: 5087535554
FaxNumber: 5087527245
Other Information
ProviderEnumerationDate: 08/09/2007
LastUpdateDate: 01/23/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163WP0808XRN206918MAY Nursing Service ProvidersRegistered NursePsych/Mental Health
364SF0001X206917MAN Physician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health

No ID Information.


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