Provider Demographics
NPI:1760769657
Name:CHILDERS, KIMBERLY KATHRYN (MS, CGC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KATHRYN
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:KATHRYN
Other - Last Name:VANDE WYDEVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CGC
Mailing Address - Street 1:181 S BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4504
Mailing Address - Country:US
Mailing Address - Phone:818-748-4761
Mailing Address - Fax:818-748-4711
Practice Address - Street 1:181 S BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4504
Practice Address - Country:US
Practice Address - Phone:818-748-4762
Practice Address - Fax:818-748-4711
Is Sole Proprietor?:No
Enumeration Date:2011-11-07
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246.000119170300000X
CAGC000547170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS