Healthcare Provider Details

I. General information

NPI: 1043892995
Provider Name (Legal Business Name): KIMBERLY NELSON HOMENIUK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY NELSON PHD

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 04/21/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 5TH ST STE 405
SAN FRANCISCO CA
94107-1541
US

IV. Provider business mailing address

14329 GERONIMO
LEANDER TX
78641-9698
US

V. Phone/Fax

Practice location:
  • Phone: 415-231-5333
  • Fax: 415-231-5332
Mailing address:
  • Phone: 512-745-7598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number76851
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: