Provider Demographics
NPI:1891202255
Name:CARDILLA, KIM (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:CARDILLA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 FRONT ST STE 320
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4536
Mailing Address - Country:US
Mailing Address - Phone:831-710-1455
Mailing Address - Fax:888-617-7565
Practice Address - Street 1:740 FRONT ST STE 320
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4536
Practice Address - Country:US
Practice Address - Phone:831-710-1455
Practice Address - Fax:888-617-7565
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29537103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist