Provider Demographics
NPI:1609233055
Name:KIMBALL, MISHKA CLAVIJO
Entity Type:Individual
Prefix:MRS
First Name:MISHKA
Middle Name:CLAVIJO
Last Name:KIMBALL
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 1:20300 VENTURA BLVD STE 330
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-0904
Mailing Address - Country:US
Mailing Address - Phone:818-253-9404
Mailing Address - Fax:
Practice Address - Street 1:20300 VENTURA BLVD STE 330
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-0904
Practice Address - Country:US
Practice Address - Phone:818-253-9404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-15
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112986106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist