1023446440 NPI number — MRS. KIMBERLY ELLEN BERMUDEZ LCSW

Table of content: MRS. KIMBERLY ELLEN BERMUDEZ LCSW (NPI 1023446440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023446440 NPI number — MRS. KIMBERLY ELLEN BERMUDEZ LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERMUDEZ
Provider First Name:
KIMBERLY
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOFFMAN
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023446440
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
875 PRIMOS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80302-9213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-809-9790
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3980 BROADWAY ST STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80304-1161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-809-9790
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  1972 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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