Basic Information
| Provider Information | |||||||||
| NPI: | 1841708393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOC | ||||||||
| FirstName: | KIMMING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7862 FIRST DRAW WAY | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958285356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166066204 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4433 FLORIN RD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958232527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162342577 | ||||||||
| FaxNumber: | 9162362577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2018 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CA | N | Behavioral Health & Social Service Providers | Counselor | 104100000X | ASW80999 | CA | N | Behavioral Health & Social Service Providers | Social Worker | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.