Provider Demographics
NPI:1366730806
Name:SHIN, KIMBERLY LORNA (CADC, ATR-BC, LPCC,)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:LORNA
Last Name:SHIN
Suffix:
Gender:F
Credentials:CADC, ATR-BC, LPCC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3468 NORWALK PL
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-2965
Mailing Address - Country:US
Mailing Address - Phone:707-294-5545
Mailing Address - Fax:
Practice Address - Street 1:831 ALAMO DR STE 5C
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-5343
Practice Address - Country:US
Practice Address - Phone:707-624-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CALPCC5691101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4848210000Medicare Oscar/Certification