Healthcare Provider Details

I. General information

NPI: 1730691510
Provider Name (Legal Business Name): KIMBERLY ROSE HEGG MFTI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2017
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 ROSECRANS AVE STE 500
MANHATTAN BEACH CA
90266-3771
US

IV. Provider business mailing address

2513 VANDERBILT LN # B
REDONDO BEACH CA
90278-3215
US

V. Phone/Fax

Practice location:
  • Phone: 310-560-8357
  • Fax:
Mailing address:
  • Phone: 310-560-8357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF101218
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT118058
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: