Provider Demographics
NPI:1992421309
Name:AGUAYO, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:AGUAYO
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 1:801 CORPORATE CENTER DR STE 210
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2627
Mailing Address - Country:US
Mailing Address - Phone:909-618-0974
Mailing Address - Fax:
Practice Address - Street 1:9570 CENTER AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5842
Practice Address - Country:US
Practice Address - Phone:909-980-4755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician