Healthcare Provider Details

I. General information

NPI: 1134572365
Provider Name (Legal Business Name): KIMBERLY PAULY LPCC, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2016
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 MORENA BLVD FL 2
SAN DIEGO CA
92110-3815
US

IV. Provider business mailing address

3255 CAMINO DEL RIO S
SAN DIEGO CA
92108-3806
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-8703
  • Fax:
Mailing address:
  • Phone: 619-584-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1491
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number004819
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: