Healthcare Provider Details

I. General information

NPI: 1598697831
Provider Name (Legal Business Name): KIMBERLY SOTO BANUELOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 N GAREY AVE
POMONA CA
91767-2722
US

IV. Provider business mailing address

2008 N GAREY AVE
POMONA CA
91767-2722
US

V. Phone/Fax

Practice location:
  • Phone: 909-623-6131
  • Fax: 909-865-9281
Mailing address:
  • Phone: 909-623-6131
  • Fax: 909-865-9281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberF7651541
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: