Provider Demographics
NPI:1659442275
Name:ABBANANTO, KIM R (LMFT #42108)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:R
Last Name:ABBANANTO
Suffix:
Gender:F
Credentials:LMFT #42108
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 VERDUGO WAY STE 204
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:124 CARMEN LN
Practice Address - Street 2:SUITES J AND L
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-7768
Practice Address - Country:US
Practice Address - Phone:805-928-8622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42108106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist