Provider Demographics
NPI:1730232356
Name:HALL, KIMBERLY (PSYD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19144 HAWKHILL AVE
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-6533
Mailing Address - Country:US
Mailing Address - Phone:951-264-1245
Mailing Address - Fax:
Practice Address - Street 1:19144 HAWKHILL AVE
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-6533
Practice Address - Country:US
Practice Address - Phone:951-264-1245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19448103T00000X
CAPSY19448103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist