Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PSY17209 | CA |
Y | 103TC0700X | Clinical Psychologist | PSY17209 | CA |
NPI | 1003968066 |
---|---|
Provider Name | Dr. Kimberly Lisa Vander Dussen |
First Address | Placentia, CA 92870-6102 |
Second Address | Placentia, CA 92870-6102 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/01/2007 |
Last Update Date | 08/07/2007 |