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General NPI Number Information
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NPI Number | 1003968066
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Entity Type | Individual
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Provider Name | KIMBERLY LISA VANDER DUSSEN PSY. D.
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Gender | Female
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Dates
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Enumeration Date | 01/18/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 101 S KRAEMER BLVD STE 236
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City | PLACENTIA
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State | CA
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Zip | 92870-6102
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Country | US
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Telephone | 714-329-6080
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Fax | 714-491-7215
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Provider Business Mailing Address
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Address Line | 101 S KRAEMER BLVD STE 236
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City | PLACENTIA
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State | CA
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Zip | 92870-6102
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Country | US
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Telephone | 714-329-6080
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Fax | 714-491-7215
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY17209
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License Number State | CA
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