MEDICARE: DR. KIM CATHERINE VAN DUSEN PSY.D., LMFT, RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	61664	CA
2	106H00000X	Marriage & Family Therapist	61664	CA

General Provider Information

NPI Number	:	1225333214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIM CATHERINE VAN DUSEN PSY.D., LMFT, RPT

Provider Business Mailing Address
First Line	:	30777 RANCHO CALIFORNIA RD UNIT 891412
Second Line	:
City	:	TEMECULA
State	:	CA
Zip	:	92589-6058
Country	:	US
Telephone Number	:	760-278-1425
Fax Number	:	760-692-6470

Provider Business Practice Location Address
First Line	:	9466 BLACK MOUNTAIN RD STE 100
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-4550
Country	:	US
Telephone Number	:	858-689-2027
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2011
Last Update Date	:	12/03/2019

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