Provider Demographics
NPI:1568953990
Name:NGUYEN, KIMBERLY DUONG
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DUONG
Last Name:NGUYEN
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 1:27777 INKSTER RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5326
Mailing Address - Country:US
Mailing Address - Phone:248-436-4400
Mailing Address - Fax:
Practice Address - Street 1:2275 35TH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3275
Practice Address - Country:US
Practice Address - Phone:510-640-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2019-11-04
Deactivation Date:2019-09-17
Deactivation Code:
Reactivation Date:2019-10-30
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94159125D63001Medicaid