Healthcare Provider Details

I. General information

NPI: 1871606327
Provider Name (Legal Business Name): KIM B BARRUS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30495 CANWOOD ST STE 101
AGOURA HILLS CA
91301-4331
US

IV. Provider business mailing address

30495 CANWOOD ST STE 101
AGOURA HILLS CA
91301-4331
US

V. Phone/Fax

Practice location:
  • Phone: 818-707-7366
  • Fax: 818-707-2672
Mailing address:
  • Phone: 818-707-7366
  • Fax: 818-707-2672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY6155
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: