Provider Demographics
NPI:1154090017
Name:KIESCHNICK, DUSTIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:
Last Name:KIESCHNICK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3221
Mailing Address - Street 2:
Mailing Address - City:OLYMPIC VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:96146-3221
Mailing Address - Country:US
Mailing Address - Phone:910-467-3217
Mailing Address - Fax:
Practice Address - Street 1:198 TIGER TAIL RD
Practice Address - Street 2:
Practice Address - City:OLYMPIC VALLEY
Practice Address - State:CA
Practice Address - Zip Code:96146-9783
Practice Address - Country:US
Practice Address - Phone:910-467-3217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32828103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical