Provider Demographics
NPI:1972984110
Name:LEGH-PAGE, KIMBERLY JUNE (PHD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:JUNE
Last Name:LEGH-PAGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 RANCHERIA DR
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-9522
Mailing Address - Country:US
Mailing Address - Phone:832-265-1424
Mailing Address - Fax:
Practice Address - Street 1:1620 CUMMINS DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-6400
Practice Address - Country:US
Practice Address - Phone:832-265-1424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-12
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
CA87753106H00000X
CAPSY35504103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty