Provider Demographics
NPI:1164941183
Name:LISTER- GUTIERREZ, KIMBERLY DENISE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DENISE
Last Name:LISTER- GUTIERREZ
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 1:303 E 52ND ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-4513
Mailing Address - Country:US
Mailing Address - Phone:562-882-3269
Mailing Address - Fax:
Practice Address - Street 1:303 E 52ND STREET
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011
Practice Address - Country:US
Practice Address - Phone:562-882-3269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA169743101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$OtherMEDICAL
CA$$$$$$$$$Medicaid