Provider Demographics
NPI:1861696916
Name:KMETZ, KIM (MFT)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:KMETZ
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28632 ROADSIDE DR STE 145
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-6016
Mailing Address - Country:US
Mailing Address - Phone:818-801-1999
Mailing Address - Fax:
Practice Address - Street 1:28632 ROADSIDE DR STE 145
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-6016
Practice Address - Country:US
Practice Address - Phone:818-801-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT20169106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist