Provider Demographics
NPI:1508047051
Name:SAMUELS, KIMALLY L (MFT)
Entity Type:Individual
Prefix:MISS
First Name:KIMALLY
Middle Name:L
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MISS
Other - First Name:KIMALLY
Other - Middle Name:L
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT
Mailing Address - Street 1:640 BAILEY RD # 482
Mailing Address - Street 2:
Mailing Address - City:BAY POINT
Mailing Address - State:CA
Mailing Address - Zip Code:94565-4306
Mailing Address - Country:US
Mailing Address - Phone:925-226-8780
Mailing Address - Fax:
Practice Address - Street 1:2225 BUCHANAN RD STE H
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4209
Practice Address - Country:US
Practice Address - Phone:925-226-8780
Practice Address - Fax:925-777-9446
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44594106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist