MEDICARE: DR. KIMBERLY FARA CORBETT PSYD, 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	103TC0700X	Clinical Psychologist	PSY21669	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	776634000	OTHER	CA	MAGELLAN PIN
2	352923	OTHER	CA	MHN PROVIDER ID NUMBER
3	0PL216690	OTHER	CA	TRICARE PIN
4	0PL216690	OTHER	CA	BLUE SHIELD OF CA PIN
5	7314642	OTHER	CA	AETNA PIN
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235239823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMBERLY FARA CORBETT PSYD, MFT

Provider Business Mailing Address
First Line	:	4789 MOUNT ASHMUN DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-3952
Country	:	US
Telephone Number	:	619-298-2098
Fax Number	:	619-298-2098

Provider Business Practice Location Address
First Line	:	4411 30TH ST STE 101
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-4286
Country	:	US
Telephone Number	:	619-298-2098
Fax Number	:	619-298-2098

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

Provider Enumeration Date	:	09/23/2006
Last Update Date	:	09/11/2019

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