Provider Demographics
NPI:1184755753
Name:ANAYA, KIM COLLEEN
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:COLLEEN
Last Name:ANAYA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 N WINERY AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-4807
Mailing Address - Country:US
Mailing Address - Phone:559-216-0125
Mailing Address - Fax:
Practice Address - Street 1:2140 N WINERY AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-4807
Practice Address - Country:US
Practice Address - Phone:559-216-0125
Practice Address - Fax:559-216-0125
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94028794103TC0700X
CA02-100000101YA0400X
CAPSB94026395101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1184755753Medicaid
CA101076OtherDRUG MEDI-CAL