Healthcare Provider Details

I. General information

NPI: 1710825542
Provider Name (Legal Business Name): KIMBERLY KYNA NICOLE GAOA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 W PACIFIC COAST HWY
LONG BEACH CA
90806-5237
US

IV. Provider business mailing address

514 W PACIFIC COAST HWY
LONG BEACH CA
90806-5237
US

V. Phone/Fax

Practice location:
  • Phone: 562-432-0713
  • Fax: 562-972-3617
Mailing address:
  • Phone: 562-432-0713
  • Fax: 562-972-3617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25304
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: