Provider Demographics
NPI:1851707947
Name:MOSLEY-WILLIAMS, KIMBERLY TAN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:TAN
Last Name:MOSLEY-WILLIAMS
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:PO BOX 1502
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-0502
Mailing Address - Country:US
Mailing Address - Phone:626-472-6000
Mailing Address - Fax:
Practice Address - Street 1:1000 N ALAMEDA ST STE 390
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-1804
Practice Address - Country:US
Practice Address - Phone:213-804-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA667851041C0700X
CA115581172V00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172V00000XOther Service ProvidersCommunity Health Worker