Provider Demographics
NPI:1861584922
Name:HAGAN, KIMBERLY MARIE (PHD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:HAGAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 N STATE COLLEGE BLVD
Mailing Address - Street 2:FULLERTON COUNSELING & MEDICAL GROUP INC
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831
Mailing Address - Country:US
Mailing Address - Phone:714-990-0700
Mailing Address - Fax:714-990-0142
Practice Address - Street 1:2228 N STATE COLLEGE BLVD
Practice Address - Street 2:FULLERTON COUNSELING & MEDICAL GROUP INC
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831
Practice Address - Country:US
Practice Address - Phone:714-990-0700
Practice Address - Fax:714-990-0142
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15282103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP15282Medicare ID - Type Unspecified