Healthcare Provider Details

I. General information

NPI: 1588894620
Provider Name (Legal Business Name): KIMBERLY BASS DITTU PSYD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MOTOR AVE
LOS ANGELES CA
90034-3740
US

IV. Provider business mailing address

3200 MOTOR AVE
LOS ANGELES CA
90034-3740
US

V. Phone/Fax

Practice location:
  • Phone: 310-836-1223
  • Fax:
Mailing address:
  • Phone: 310-836-1223
  • Fax: 310-836-1223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSB94026042
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW63288
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License NumberPSB94026042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: