Provider Demographics
NPI:1396859559
Name:VANGODA, KIMBERLY LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:LYNN
Last Name:VANGODA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:VAPSHCS AMERICAN LAKE DIVISION
Mailing Address - Street 2:116-POC
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98493-0001
Mailing Address - Country:US
Mailing Address - Phone:253-583-1688
Mailing Address - Fax:253-589-4163
Practice Address - Street 1:VAPSHCS AMERICAN LAKE DIVISION
Practice Address - Street 2:116-POC
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493-0001
Practice Address - Country:US
Practice Address - Phone:253-583-1688
Practice Address - Fax:253-589-4163
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002993103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical