Healthcare Provider Details

I. General information

NPI: 1932033677
Provider Name (Legal Business Name): DUSTIN KIESCHNICK, PSYD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

497 TAHOE KEYS BLVD APT 35
SOUTH LAKE TAHOE CA
96150-3841
US

IV. Provider business mailing address

497 TAHOE KEYS BLVD APT 35
SOUTH LAKE TAHOE CA
96150-3841
US

V. Phone/Fax

Practice location:
  • Phone: 910-467-3217
  • Fax:
Mailing address:
  • Phone: 910-467-3217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DUSTIN KIESCHNICK
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 530-208-5714