Provider Demographics
NPI:1073099552
Name:BUTTS, KIMBERLY LYLES
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:LYLES
Last Name:BUTTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 A ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4148
Mailing Address - Country:US
Mailing Address - Phone:510-459-5294
Mailing Address - Fax:
Practice Address - Street 1:545 ESTUDILLO AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4611
Practice Address - Country:US
Practice Address - Phone:510-352-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 175T00000X
CAMPSS-MKHLRT172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB9627718OtherCALIFORNIA ID