Provider Demographics
NPI:1063669489
Name:VANHORN, KIMBERLAND DALE (RASI)
Entity Type:Individual
Prefix:
First Name:KIMBERLAND
Middle Name:DALE
Last Name:VANHORN
Suffix:
Gender:F
Credentials:RASI
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 6470
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-6470
Mailing Address - Country:US
Mailing Address - Phone:707-995-3235
Mailing Address - Fax:
Practice Address - Street 1:6885 OLD HIGHWAY 53
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-6470
Practice Address - Country:US
Practice Address - Phone:707-995-3235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-V0808221354101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)