Provider Demographics
NPI:1063867737
Name:FANNING-SHILES, KIMBERLY (LMFT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FANNING-SHILES
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7365 CARNELIAN ST
Mailing Address - Street 2:STE. 202
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1158
Mailing Address - Country:US
Mailing Address - Phone:909-376-5125
Mailing Address - Fax:
Practice Address - Street 1:7365 CARNELIAN ST
Practice Address - Street 2:STE. 202
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1158
Practice Address - Country:US
Practice Address - Phone:909-376-5125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 80277101YM0800X
CA98512106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health