Provider Demographics
NPI:1932239522
Name:CLAYBORN, KIMBERLY ESTELLE (LICENSED MARRIAGE &)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ESTELLE
Last Name:CLAYBORN
Suffix:
Gender:F
Credentials:LICENSED MARRIAGE &
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 45196
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045
Mailing Address - Country:US
Mailing Address - Phone:323-419-8274
Mailing Address - Fax:
Practice Address - Street 1:420 S. BEVERLY DRIVE #100
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212
Practice Address - Country:US
Practice Address - Phone:323-419-8274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44162101YP2500X
CAMFC44162106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional