Provider Demographics
NPI:1720301955
Name:DITTERICH, KIRK W (PSYD)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:W
Last Name:DITTERICH
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 60901
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96160-9001
Mailing Address - Country:US
Mailing Address - Phone:530-582-6862
Mailing Address - Fax:530-550-1670
Practice Address - Street 1:10956 DONNER PASS RD
Practice Address - Street 2:STE 330
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-4861
Practice Address - Country:US
Practice Address - Phone:530-582-6450
Practice Address - Fax:530-582-6430
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23279103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical