Provider Demographics
NPI:1033742036
Name:REDLICKI, KIMBERLY JAMIE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JAMIE
Last Name:REDLICKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JAMIE
Other - Last Name:RICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4823 W CRESTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-1340
Mailing Address - Country:US
Mailing Address - Phone:310-499-3220
Mailing Address - Fax:
Practice Address - Street 1:4823 W CRESTVIEW AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1340
Practice Address - Country:US
Practice Address - Phone:310-499-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA133096106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health