Provider Demographics
NPI:1245411636
Name:DOUGLASS, KIMBERLEY RENEE (MSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:RENEE
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10260 MONO CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7117
Mailing Address - Country:US
Mailing Address - Phone:209-474-2227
Mailing Address - Fax:
Practice Address - Street 1:10260 MONO CT
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-7117
Practice Address - Country:US
Practice Address - Phone:209-474-2227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)