Provider Demographics
NPI:1467067363
Name:BLAINE, KIMBERLEY CLAYTON (LMFT)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:CLAYTON
Last Name:BLAINE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1443 E WASHINGTON BLVD STE 185
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-2650
Mailing Address - Country:US
Mailing Address - Phone:310-497-0088
Mailing Address - Fax:
Practice Address - Street 1:1443 E WASHINGTON BLVD STE 185
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2650
Practice Address - Country:US
Practice Address - Phone:310-497-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT34946101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health