Healthcare Provider Details

I. General information

NPI: 1154483816
Provider Name (Legal Business Name): KIMBERLY DIRKS PANGANIBAN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY MICHELLE DIRKS IMF

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16935 W BERNARDO DR SUITE 208
SAN DIEGO CA
92127-1634
US

IV. Provider business mailing address

16935 W BERNARDO DR SUITE 208
SAN DIEGO CA
92127-1634
US

V. Phone/Fax

Practice location:
  • Phone: 858-361-6016
  • Fax: 858-451-0333
Mailing address:
  • Phone: 858-361-6016
  • Fax: 858-451-0333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number54218
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC52717
License Number StateCA
# 3
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: