Provider Demographics
NPI:1538874201
Name:COREA, KIMBERLY STEPHANIE
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:STEPHANIE
Last Name:COREA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2935 E AVENUE R7
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-6365
Mailing Address - Country:US
Mailing Address - Phone:661-208-2347
Mailing Address - Fax:
Practice Address - Street 1:4401 CRENSHAW BLVD STE 215
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-1200
Practice Address - Country:US
Practice Address - Phone:323-291-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABACB793210106S00000X
CA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician