Provider Demographics
NPI:1023579596
Name:TELLMAN, KIMBERLY A (LMFT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:TELLMAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 737
Mailing Address - Street 2:
Mailing Address - City:MEADOW VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95722-0737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 RIVER ROCK DR STE 106
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-2093
Practice Address - Country:US
Practice Address - Phone:530-368-9315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110805106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist