Healthcare Provider Details

I. General information

NPI: 1578915997
Provider Name (Legal Business Name): KIMBERLY MACKAY LCSW 99074
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2016
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WILSHIRE BLVD STE 204
SANTA MONICA CA
90401-1737
US

IV. Provider business mailing address

720 WILSHIRE BLVD STE 204
SANTA MONICA CA
90401-1737
US

V. Phone/Fax

Practice location:
  • Phone: 323-510-8932
  • Fax:
Mailing address:
  • Phone: 323-510-8932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW99074
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: