Provider Demographics
NPI:1649049560
Name:COULSON, KIMBERLEY ANN (RADT I)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:ANN
Last Name:COULSON
Suffix:
Gender:F
Credentials:RADT I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:
Practice Address - Street 1:1750 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2754
Practice Address - Country:US
Practice Address - Phone:619-255-5058
Practice Address - Fax:619-269-8349
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-MLEBUO175T00000X
CARH0013340624101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist