Provider Demographics
NPI:1568857217
Name:CHAN, KIMBERLY L (MFT)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:L
Last Name:CHAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29123
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-0123
Mailing Address - Country:US
Mailing Address - Phone:888-930-1941
Mailing Address - Fax:
Practice Address - Street 1:2820 GLENDALE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-2723
Practice Address - Country:US
Practice Address - Phone:888-930-1941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93626106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist