Healthcare Provider Details

I. General information

NPI: 1508208802
Provider Name (Legal Business Name): KIMBERLY ANN DE SERPA L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2013
Last Update Date: 07/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 TROUT GULCH RD
APTOS CA
95003-2617
US

IV. Provider business mailing address

3130 TROUT GULCH RD
APTOS CA
95003-2617
US

V. Phone/Fax

Practice location:
  • Phone: 831-588-7388
  • Fax:
Mailing address:
  • Phone: 831-588-7388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 28624
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: