=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245458132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIMBERLY CORBETT, PSY.D., A PSYCHOLOGICAL CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 09/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4411 30TH ST STE 101
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92116-4286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-298-2098
-----------------------------------------------------
Fax | 619-298-2098
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6757 FRIARS RD UNIT 21
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-298-0169
-----------------------------------------------------
Fax | 619-298-0169
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DR. KIMBERLY FARA CORBETT
-----------------------------------------------------
Credential | PSY.D., M.F.T.
-----------------------------------------------------
Telephone | 619-298-0169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC39583
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY21669
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------