1508208802 NPI number — MS. KIMBERLY ANN DE SERPA L.C.S.W.

Table of content: MS. KIMBERLY ANN DE SERPA L.C.S.W. (NPI 1508208802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508208802 NPI number — MS. KIMBERLY ANN DE SERPA L.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE SERPA
Provider First Name:
KIMBERLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508208802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3130 TROUT GULCH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APTOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95003-2617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-588-7388
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3130 TROUT GULCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APTOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95003-2617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-588-7388
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2013

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:  LCS 28624 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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