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NPI Code Detail

MEDICARE: DR. KIMBERLY K SHANE PSY.D

MEDICARE: DR. KIMBERLY K SHANE PSY.D
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical PsychologistPSY21138CA

General Provider Information

NPI Number : 1053408419
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KIMBERLY K SHANE PSY.D
Provider Business Mailing Address
First Line : 1404 BECKWITH AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90049-3618
Country : US
Telephone Number : 310-625-4165
Fax Number :
Provider Business Practice Location Address
First Line : 3200 MOTOR AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90034-3740
Country : US
Telephone Number : 310-836-1223
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/06/2006
Last Update Date : 10/03/2023

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