Provider Demographics
NPI:1760025886
Name:ELLIOTT, KIMBERLY KAY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:ELLIOTT
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 1:1565 FRESIA WAY
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-3041
Mailing Address - Country:US
Mailing Address - Phone:530-356-8427
Mailing Address - Fax:
Practice Address - Street 1:1255 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0814
Practice Address - Country:US
Practice Address - Phone:530-246-2467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA925801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA92580OtherLCSW