Provider Demographics
NPI:1164446480
Name:EVANS, KIMBERLY (PHD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W BEECH ST UNIT 1201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2961
Mailing Address - Country:US
Mailing Address - Phone:917-721-0757
Mailing Address - Fax:
Practice Address - Street 1:425 W BEECH ST UNIT 1201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2961
Practice Address - Country:US
Practice Address - Phone:917-721-0757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31655103TC0700X
NY13781103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02006462Medicaid
NY02006462Medicaid