Healthcare Provider Details

I. General information

NPI: 1225333214
Provider Name (Legal Business Name): KIM CATHERINE VAN DUSEN PSY.D., LMFT, RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2011
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9466 BLACK MOUNTAIN RD STE 100
SAN DIEGO CA
92126-4550
US

IV. Provider business mailing address

30777 RANCHO CALIFORNIA RD UNIT 891412
TEMECULA CA
92589-6058
US

V. Phone/Fax

Practice location:
  • Phone: 858-689-2027
  • Fax:
Mailing address:
  • Phone: 760-278-1425
  • Fax: 760-692-6470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number61664
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number61664
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: