Healthcare Provider Details

I. General information

NPI: 1982136727
Provider Name (Legal Business Name): MRS. KIMBERLY MACIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 MEADE AVE
SAN DIEGO CA
92116-4251
US

IV. Provider business mailing address

2929 MEADE AVE
SAN DIEGO CA
92116-4251
US

V. Phone/Fax

Practice location:
  • Phone: 619-281-8313
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5752
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: