Provider Demographics
NPI:1457806770
Name:KIMBERLY TANGEN PHD, LICENSED PSYCHOLOGIST, INC.
Entity type:Organization
Organization Name:KIMBERLY TANGEN PHD, LICENSED PSYCHOLOGIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:TANGEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD QME
Authorized Official - Phone:323-538-4779
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 22865103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty