MEDICARE: MS. KIMBERLY L CHAN MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	93626	CA

General Provider Information

NPI Number	:	1568857217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY L CHAN MFT

Provider Business Mailing Address
First Line	:	PO BOX 29123
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-0123
Country	:	US
Telephone Number	:	888-930-1941
Fax Number	:

Provider Business Practice Location Address
First Line	:	2820 GLENDALE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-2723
Country	:	US
Telephone Number	:	888-930-1941
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2015
Last Update Date	:	11/29/2016

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