Provider Demographics
NPI:1073796058
Name:TANGEN, KIMBERLY ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANNE
Last Name:TANGEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8117 W MANCHESTER AVE # 885
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-8211
Mailing Address - Country:US
Mailing Address - Phone:323-538-4779
Mailing Address - Fax:323-817-1150
Practice Address - Street 1:4519 ADMIRALTY WAY STE 110
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5455
Practice Address - Country:US
Practice Address - Phone:323-538-4779
Practice Address - Fax:323-817-1150
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22865103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical