Provider Demographics
NPI:1417545930
Name:RICHARDSON, MISS-KIMILLE MICHELA (AMFT, APCC)
Entity Type:Individual
Prefix:
First Name:MISS-KIMILLE
Middle Name:MICHELA
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:AMFT, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6541 RAVEN CIR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-0402
Mailing Address - Country:US
Mailing Address - Phone:512-426-8055
Mailing Address - Fax:
Practice Address - Street 1:9567 ARROW RTE STE M
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4550
Practice Address - Country:US
Practice Address - Phone:909-774-1134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA113819106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist