Basic Information
| Provider Information | |||||||||
| NPI: | 1588901938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | LORAINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 221611 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958228611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192444237 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 PRISON RD | ||||||||
| Address2: | |||||||||
| City: | REPRESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956713001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169858610 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2013 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY27907 | CA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.