Provider Demographics
NPI:1336969641
Name:HALEY, KIMBERLY (MT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:HALEY
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 WASHINGTON PL STE 112
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5000
Mailing Address - Country:US
Mailing Address - Phone:323-332-1485
Mailing Address - Fax:
Practice Address - Street 1:11600 WASHINGTON PL STE 112
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5000
Practice Address - Country:US
Practice Address - Phone:323-332-1485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76986225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist