Basic Information
| Provider Information | |||||||||
| NPI: | 1235323569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHULTZ | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | MELISSA | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 MISSION AVE | ||||||||
| Address2: | A | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92058 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 MISSION AVE | ||||||||
| Address2: | A | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609674475 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2007 | ||||||||
| LastUpdateDate: | 01/03/2012 | ||||||||
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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 | 1041C0700X | 28093 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.