Provider Demographics
NPI:1114504917
Name:CORTES VILLAVICENCIO, KIMBERLY CLAYRE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CLAYRE
Last Name:CORTES VILLAVICENCIO
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 1:517 ACACIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-4221
Mailing Address - Country:US
Mailing Address - Phone:408-616-0569
Mailing Address - Fax:
Practice Address - Street 1:517 ACACIA AVE
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-4221
Practice Address - Country:US
Practice Address - Phone:650-787-6667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-19-92768106S00000X
CA1-23-69986103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician