=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811917776
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLEY WOODWORTH MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 11/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3350 LA JOLLA VILLAGE DR # 118S
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92161-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-642-3181
-----------------------------------------------------
Fax | 858-552-4311
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3350 LA JOLLA VILLAGE DR # S118
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92161-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-642-3181
-----------------------------------------------------
Fax | 858-552-4311
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCS10298
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------