Provider Demographics
NPI:1598067787
Name:BERBENA, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BERBENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:AIELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 W BRIGGSMORE AVE
Mailing Address - Street 2:SUITE I
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-3839
Mailing Address - Country:US
Mailing Address - Phone:209-526-1440
Mailing Address - Fax:
Practice Address - Street 1:2000 W BRIGGSMORE AVE
Practice Address - Street 2:SUITE I
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3839
Practice Address - Country:US
Practice Address - Phone:209-526-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85743106H00000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional