Provider Demographics
NPI:1912662164
Name:KIMBRELL, SHELLEY DAWN (MFT TRAINEE, SUDRC,)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:DAWN
Last Name:KIMBRELL
Suffix:
Gender:F
Credentials:MFT TRAINEE, SUDRC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29564 YOSEMITE SPRINGS PARKWAY
Mailing Address - Street 2:PMB34
Mailing Address - City:COARSEGOLD
Mailing Address - State:CA
Mailing Address - Zip Code:93614
Mailing Address - Country:US
Mailing Address - Phone:559-580-5391
Mailing Address - Fax:
Practice Address - Street 1:49370 ROAD 426 STE B
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:CA
Practice Address - Zip Code:93644-9052
Practice Address - Country:US
Practice Address - Phone:559-580-5391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
106H00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist