=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205647047
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLEY GHEZZI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2025
-----------------------------------------------------
Last Update Date | 05/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5805 CALLAGHAN RD STE 206
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78228-1127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-488-7685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12790 FM 1560 N #1714
-----------------------------------------------------
City | HELOTES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78023-8777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 92134
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------