Provider Demographics
NPI:1457800039
Name:CENTARO, KYMBERLY
Entity Type:Individual
Prefix:
First Name:KYMBERLY
Middle Name:
Last Name:CENTARO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KYMBERLY
Other - Middle Name:
Other - Last Name:CENTARO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1198
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95812-1198
Mailing Address - Country:US
Mailing Address - Phone:707-481-7882
Mailing Address - Fax:
Practice Address - Street 1:634 PRESSLEY ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5526
Practice Address - Country:US
Practice Address - Phone:707-484-1326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XMedicaid