Provider Demographics
NPI:1184044554
Name:FITZSIMMONS, KIMBERLY SUE (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:FITZSIMMONS
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1346 EDGEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3444
Mailing Address - Country:US
Mailing Address - Phone:909-496-1445
Mailing Address - Fax:
Practice Address - Street 1:11777 SEBASTIAN WAY
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0707
Practice Address - Country:US
Practice Address - Phone:909-989-9724
Practice Address - Fax:909-989-0249
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF84203106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist