Provider Demographics
NPI:1104562396
Name:D ANGELO, KIMBERLY J (MC 61115650)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:J
Last Name:D ANGELO
Suffix:
Gender:F
Credentials:MC 61115650
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3823 222ND PL SE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-4220
Mailing Address - Country:US
Mailing Address - Phone:206-830-0589
Mailing Address - Fax:
Practice Address - Street 1:15446 BEL RED RD STE 200
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-5517
Practice Address - Country:US
Practice Address - Phone:425-295-7697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61115650101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health