Provider Demographics
NPI:1235682824
Name:DOCTOLERO, KIMBERLY DAWN MANZANO
Entity Type:Individual
Prefix:
First Name:KIMBERLY DAWN
Middle Name:MANZANO
Last Name:DOCTOLERO
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 1:12433 RIVERSIDE DR APT 2
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3564
Mailing Address - Country:US
Mailing Address - Phone:702-340-6356
Mailing Address - Fax:
Practice Address - Street 1:7313 WHITTIER AVE
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1132
Practice Address - Country:US
Practice Address - Phone:424-442-9129
Practice Address - Fax:310-943-3821
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA83-1142000Medicaid