Provider Demographics
NPI:1053711630
Name:MCGOWAN, KIMBERLY
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:MCGOWAN
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 1:266 BERMUDA GREENS AVE
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-4390
Mailing Address - Country:US
Mailing Address - Phone:954-536-1121
Mailing Address - Fax:
Practice Address - Street 1:460 TOWN PLAZA AVE STE 260
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-5139
Practice Address - Country:US
Practice Address - Phone:904-599-1243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health