Provider Demographics
NPI:1093174336
Name:BONACCORSO, KIM
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:BONACCORSO
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:BONACCORSO
Other - Last Name:SHIPMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2100 N BROADWAY
Mailing Address - Street 2:101
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-2624
Mailing Address - Country:US
Mailing Address - Phone:714-245-6881
Mailing Address - Fax:
Practice Address - Street 1:2100 N BROADWAY
Practice Address - Street 2:101
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-2624
Practice Address - Country:US
Practice Address - Phone:714-245-6881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA9578135OtherDRIVER LICENSE NUMBER