Provider Demographics
NPI:1245249523
Name:KIMBAUER, ELLI (PSYD)
Entity type:Individual
Prefix:DR
First Name:ELLI
Middle Name:
Last Name:KIMBAUER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 MASON MALL
Mailing Address - Street 2:6A
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-4334
Mailing Address - Country:US
Mailing Address - Phone:707-464-7662
Mailing Address - Fax:707-464-7864
Practice Address - Street 1:1080 MASON MALL
Practice Address - Street 2:6A
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-4334
Practice Address - Country:US
Practice Address - Phone:707-464-7662
Practice Address - Fax:707-464-7864
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18816103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL188161Medicare UPIN