Basic Information
Provider Information | |||||||||
NPI: | 1427244813 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CORP | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | MFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BARANICK | ||||||||
OtherFirstName: | KIMBERLY | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MFT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9445 FARNHAM ST | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921231308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8583804676 | ||||||||
FaxNumber: | 8585692417 | ||||||||
Practice Location | |||||||||
Address1: | 9445 FARNHAM ST | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921231308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8583804676 | ||||||||
FaxNumber: | 8585692417 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2007 | ||||||||
LastUpdateDate: | 05/14/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.