Provider Demographics
NPI:1932628443
Name:DE LA VEGA, KIMBERLY CHARLOTTE (LMFT 125331)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:CHARLOTTE
Last Name:DE LA VEGA
Suffix:
Gender:F
Credentials:LMFT 125331
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14181 YORBA ST STE 206
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2055
Mailing Address - Country:US
Mailing Address - Phone:909-477-7005
Mailing Address - Fax:
Practice Address - Street 1:14181 YORBA ST STE 206
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2055
Practice Address - Country:US
Practice Address - Phone:190-947-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100730106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist