Basic Information
| Provider Information | |||||||||
| NPI: | 1376836411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMPSON | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10526 DUBNOFF WAY | ||||||||
| Address2: | |||||||||
| City: | NORTH HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 916063921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057501961 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10526 DUBNOFF WAY | ||||||||
| Address2: | |||||||||
| City: | NORTH HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 916063921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187554950 | ||||||||
| FaxNumber: | 8187520783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2011 | ||||||||
| LastUpdateDate: | 03/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 66844 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1376836411 | 01 | CA | MEDI-CAL | OTHER |