Provider Demographics
NPI:1215173711
Name:ESTRADA, KIM MICHELLE (MA)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:MICHELLE
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LUCAS VALLEY RD STE 252
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1791
Mailing Address - Country:US
Mailing Address - Phone:415-942-3634
Mailing Address - Fax:
Practice Address - Street 1:101 LUCAS VALLEY RD STE 252
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1791
Practice Address - Country:US
Practice Address - Phone:415-942-3634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA99181106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist