Provider Demographics
NPI:1811326515
Name:HOLLOWAY, KIMBERLY PAIGE (PSYD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:PAIGE
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 609001
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-9001
Mailing Address - Country:US
Mailing Address - Phone:619-528-4600
Mailing Address - Fax:619-528-4625
Practice Address - Street 1:1550 HOTEL CIR N STE 450
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2933
Practice Address - Country:US
Practice Address - Phone:619-692-1581
Practice Address - Fax:619-692-1588
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30604103T00000X
103T00000X
CA94020152103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416OtherPCSD MEDICARE #