Healthcare Provider Details

I. General information

NPI: 1487368692
Provider Name (Legal Business Name): KIMBERLY GUMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 BAKER ST STE A
COSTA MESA CA
92626-4566
US

IV. Provider business mailing address

400 MERRIMAC WAY APT 8
COSTA MESA CA
92626-6150
US

V. Phone/Fax

Practice location:
  • Phone: 714-361-6760
  • Fax:
Mailing address:
  • Phone: 714-307-6590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: