Provider Demographics
NPI:1578915997
Name:MACKAY, KIMBERLY (LCSW 99074)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MACKAY
Suffix:
Gender:F
Credentials:LCSW 99074
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3685 MENTONE AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-7167
Mailing Address - Country:US
Mailing Address - Phone:323-301-3641
Mailing Address - Fax:
Practice Address - Street 1:2001 WILSHIRE BLVD STE 525
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5807
Practice Address - Country:US
Practice Address - Phone:949-491-7930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-09
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW79212104100000X
CA1578915997225400000X
CALCSW990741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner