MEDICARE: MRS. KIMBERLY SOPHIA NELSON MS MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	45871	CA

General Provider Information

NPI Number	:	1083866230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY SOPHIA NELSON MS MFT

Provider Business Mailing Address
First Line	:	2525 CAMINO DEL RIO S STE 315
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3784
Country	:	US
Telephone Number	:	619-280-3430
Fax Number	:

Provider Business Practice Location Address
First Line	:	325 CARLSBAD VILLAGE DR
Second Line	:	SUITE F-2
City	:	CARLSBAD
State	:	CA
Zip	:	92008-2928
Country	:	US
Telephone Number	:	619-280-3430
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	10/21/2008

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