Provider Demographics
NPI:1992347090
Name:ANDRIDGE, KIMBERLI (PSYD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLI
Middle Name:
Last Name:ANDRIDGE
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 1:599 HIGUERA ST STE F
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3853
Mailing Address - Country:US
Mailing Address - Phone:805-556-8350
Mailing Address - Fax:
Practice Address - Street 1:599 HIGUERA ST STE F
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3853
Practice Address - Country:US
Practice Address - Phone:805-556-8350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2046103TC0700X
CA27155103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY27155OtherCA LICENSE NUMBER
OR2046OtherOREGON LICENSE NUMBER