Provider Demographics
NPI:1437867769
Name:DERUSHIA, KIMBERLEE DAWN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLEE
Middle Name:DAWN
Last Name:DERUSHIA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7554 PACIFIC AVE # 690903
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-9905
Mailing Address - Country:US
Mailing Address - Phone:209-701-0105
Mailing Address - Fax:
Practice Address - Street 1:3601 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95211-0110
Practice Address - Country:US
Practice Address - Phone:209-701-0105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24992103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical