Provider Demographics
NPI:1790445781
Name:MASATSUGU, KAITLIN MIKA (LCSW)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MIKA
Last Name:MASATSUGU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 S DIAMOND BAR BLVD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1606
Mailing Address - Country:US
Mailing Address - Phone:909-396-7023
Mailing Address - Fax:
Practice Address - Street 1:253 S DIAMOND BAR BLVD
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1606
Practice Address - Country:US
Practice Address - Phone:909-860-1144
Practice Address - Fax:909-860-8307
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-18
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA810921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty