Basic Information
| Provider Information | |||||||||
| NPI: | 1609387604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURCIAGA | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CADCI | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURCIAGA | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CADCI-CICA02730220 | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 218 E COMMONWEALTH AVE | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928321911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149924770 | ||||||||
| FaxNumber: | 9496292867 | ||||||||
| Practice Location | |||||||||
| Address1: | 218 E COMMONWEALTH AVE | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928321911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149924770 | ||||||||
| FaxNumber: | 9496292867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2017 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CICA02730220 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1609387604 | 05 | CA | MEDICAID | CICA02730220 | 05 | CA | MEDICAID |