Healthcare Provider Details

I. General information

NPI: 1649049560
Provider Name (Legal Business Name): KIMBERLEY ANN COULSON RADT I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 5TH AVE
SAN DIEGO CA
92101-2754
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 619-255-5058
  • Fax: 619-269-8349
Mailing address:
  • Phone: 619-515-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRH0013340624
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-MLEBUO
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: