Provider Demographics
NPI:1437609930
Name:BAERRESEN, KIMBERLY MICHELLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:BAERRESEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:FARACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:602 LAKE ST
Mailing Address - Street 2:APT 2
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-4764
Mailing Address - Country:US
Mailing Address - Phone:714-642-9519
Mailing Address - Fax:
Practice Address - Street 1:602 LAKE ST
Practice Address - Street 2:APT 2
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-4764
Practice Address - Country:US
Practice Address - Phone:714-642-9519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27844171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor