Provider Demographics
NPI:1538636386
Name:MABANTA, KIMBERLY ANNE
Entity Type:Individual
Prefix:
First Name:KIMBERLY ANNE
Middle Name:
Last Name:MABANTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5015 ARLINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-9554
Mailing Address - Country:US
Mailing Address - Phone:916-850-5559
Mailing Address - Fax:
Practice Address - Street 1:5015 ARLINGTON WAY
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9554
Practice Address - Country:US
Practice Address - Phone:916-850-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty