Healthcare Provider Details

I. General information

NPI: 1043612005
Provider Name (Legal Business Name): KIM ELISE SPANO MA, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 - 6TH AVE. NW DOLORES, SUITE 7
CARMEL BY THE SEA CA
93921
US

IV. Provider business mailing address

PO BOX 6264
CARMEL BY THE SEA CA
93921-6264
US

V. Phone/Fax

Practice location:
  • Phone: 831-601-6880
  • Fax:
Mailing address:
  • Phone: 831-333-6162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number39791
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: