Provider Demographics
NPI:1912514480
Name:KETCHUM, KIMBERLY MARIE (ASW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 N ESCONDIDO BLVD
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-2507
Mailing Address - Country:US
Mailing Address - Phone:760-214-4304
Mailing Address - Fax:
Practice Address - Street 1:1341 N ESCONDIDO BLVD
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-2507
Practice Address - Country:US
Practice Address - Phone:760-214-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98320104100000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor