Provider Demographics
NPI:1154483816
Name:PANGANIBAN, KIMBERLY DIRKS (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DIRKS
Last Name:PANGANIBAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:DIRKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IMF
Mailing Address - Street 1:16935 W BERNARDO DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1634
Mailing Address - Country:US
Mailing Address - Phone:858-361-6016
Mailing Address - Fax:858-451-0333
Practice Address - Street 1:16935 W BERNARDO DR
Practice Address - Street 2:SUITE 208
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1634
Practice Address - Country:US
Practice Address - Phone:858-361-6016
Practice Address - Fax:858-451-0333
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA54218106H00000X
CAMFC52717106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9613OtherMEDI-CAL PROVIDER NUMBER