Provider Demographics
NPI:1114504917
Name:CORTES VILLAVICENCIO, KIMBERLY CLAYRE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CLAYRE
Last Name:CORTES VILLAVICENCIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 SCHOONER DR UNIT 101
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-4323
Mailing Address - Country:US
Mailing Address - Phone:408-616-0569
Mailing Address - Fax:
Practice Address - Street 1:2421 PORTOLA RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-8046
Practice Address - Country:US
Practice Address - Phone:801-614-2587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-23-69986103K00000X
CARBT-19-92768106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician