Provider Demographics
NPI:1003968066
Name:VANDER DUSSEN, KIMBERLY LISA (PSY D)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:LISA
Last Name:VANDER DUSSEN
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S KRAEMER BLVD STE 236
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-6102
Mailing Address - Country:US
Mailing Address - Phone:714-329-6080
Mailing Address - Fax:714-491-7215
Practice Address - Street 1:101 S KRAEMER BLVD STE 236
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-6102
Practice Address - Country:US
Practice Address - Phone:714-329-6080
Practice Address - Fax:714-491-7215
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17209103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical