Provider Demographics
NPI:1669084828
Name:HARRIS, KIMBERLY O
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:O
Last Name:HARRIS
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 1:12176 PETTIT ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-5404
Mailing Address - Country:US
Mailing Address - Phone:951-867-8118
Mailing Address - Fax:
Practice Address - Street 1:225 E. RINCON ST.
Practice Address - Street 2:SUITE 219
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879
Practice Address - Country:US
Practice Address - Phone:714-406-8052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst