Provider Demographics
NPI:1417501347
Name:WEDDERBURN, KIMBERLY SHADEAN (CTRS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SHADEAN
Last Name:WEDDERBURN
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4418 CONTINENTAL WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8930
Mailing Address - Country:US
Mailing Address - Phone:305-834-8948
Mailing Address - Fax:
Practice Address - Street 1:2200 HAYES ST FL 3
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1013
Practice Address - Country:US
Practice Address - Phone:415-750-5649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL67715225800000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000000OtherNA