Provider Demographics
NPI:1164617015
Name:NICOLSON, KIMBERLY RUTH (DSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:RUTH
Last Name:NICOLSON
Suffix:
Gender:F
Credentials:DSW, LCSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:RUTH
Other - Last Name:IVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1840 S ELENA AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5716
Mailing Address - Country:US
Mailing Address - Phone:310-737-2210
Mailing Address - Fax:
Practice Address - Street 1:1840 S ELENA AVE STE 106
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5716
Practice Address - Country:US
Practice Address - Phone:310-737-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62637104100000X
104100000X
CALCSW626731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker