Provider Demographics
NPI:1750414256
Name:DEANDA, KIMBERLE RUSK (MA, MFT, BCBA)
Entity type:Individual
Prefix:
First Name:KIMBERLE
Middle Name:RUSK
Last Name:DEANDA
Suffix:
Gender:F
Credentials:MA, MFT, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3516
Mailing Address - Country:US
Mailing Address - Phone:805-323-6174
Mailing Address - Fax:
Practice Address - Street 1:260 MAPLE CT
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3516
Practice Address - Country:US
Practice Address - Phone:805-323-6174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT47478101YM0800X
BACB525296103K00000X
CAMFC 47478106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst