Healthcare Provider Details

I. General information

NPI: 1184930844
Provider Name (Legal Business Name): MS. KIM NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2010
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31625 U.S. 101
SOLEDAD CA
93960-1020
US

IV. Provider business mailing address

62 MEADOWLAND DR
MILPITAS CA
95035-4415
US

V. Phone/Fax

Practice location:
  • Phone: 831-884-3665
  • Fax:
Mailing address:
  • Phone: 408-209-4656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY26565
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: