Provider Demographics
NPI:1730691510
Name:HEGG, KIMBERLY ROSE (MFTI)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROSE
Last Name:HEGG
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2513 VANDERBILT LN # B
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-3215
Mailing Address - Country:US
Mailing Address - Phone:310-560-8357
Mailing Address - Fax:
Practice Address - Street 1:1500 ROSECRANS AVE STE 500
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-3771
Practice Address - Country:US
Practice Address - Phone:310-560-8357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF101218106H00000X
CALMFT118058106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist