Provider Demographics
NPI:1952827628
Name:CLARK-HOLLOWAY, KIMBERLY MICHONNE
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:MICHONNE
Last Name:CLARK-HOLLOWAY
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 1:12917 CERISE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250
Mailing Address - Country:US
Mailing Address - Phone:310-675-4431
Mailing Address - Fax:310-675-4434
Practice Address - Street 1:12917 CERISE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-5520
Practice Address - Country:US
Practice Address - Phone:310-675-4431
Practice Address - Fax:310-675-4434
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1891014101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)