MEDICARE: MRS. KIMBERLY WILLMOTT

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	44380	CA
2	106H00000X	Marriage & Family Therapist	000604	NY

General Provider Information

NPI Number	:	1881706653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY WILLMOTT

Provider Business Mailing Address
First Line	:	2221 CAMINO DEL RIO S
Second Line	:	SUITE 305
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3608
Country	:	US
Telephone Number	:	619-297-8111
Fax Number	:	619-220-0437

Provider Business Practice Location Address
First Line	:	2221 CAMINO DEL RIO S
Second Line	:	SUITE 305
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3608
Country	:	US
Telephone Number	:	619-297-8111
Fax Number	:	619-220-0437

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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