Healthcare Provider Details

I. General information

NPI: 1912553702
Provider Name (Legal Business Name): KIMBERLEE ILISE MATTINGLEY BA, SUDCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3974 DUROCK RD STE 205
SHINGLE SPRINGS CA
95682-8568
US

IV. Provider business mailing address

3974 DUROCK RD STE 205
SHINGLE SPRINGS CA
95682-8568
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-4687
  • Fax:
Mailing address:
  • Phone: 530-621-4687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: