Active NPI
Kimberlee Dawn Derushia, PSYD
- Clinical Psychologist
- Stockton, CA
National Provider Identifier
1437867769
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PSY24992
- Practice address
- 1111 W Robinhood Dr Ste G
Stockton, CA 95207-5626 - Phone
- (209) 701-0105
- NPI assigned
- Nov 7, 2022
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 24992 | CA | |
| Clinical Psychologist | 103TC0700X | PSY24992 | CA | Primary |
Addresses
Primary practice location
1111 W Robinhood Dr Ste G
Stockton, CA 95207-5626
Mailing address
1111 W Robinhood Dr Ste G
Stockton, CA 95207-5626
Phone (209) 701-0105
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective May 1, 2024 through May 1, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY24992 | CA | MD | Clinical Psychologist |
| 24992 | CA | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1667779200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1723161600000",
"number": "1437867769",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1111 W ROBINHOOD DR STE G",
"city": "STOCKTON",
"state": "CA",
"postal_code": "952075626",
"telephone_number": "209-701-0105"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1111 W ROBINHOOD DR STE G",
"city": "STOCKTON",
"state": "CA",
"postal_code": "952075626",
"telephone_number": "209-701-0105"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DERUSHIA",
"first_name": "KIMBERLEE",
"middle_name": "DAWN",
"name_prefix": "Dr.",
"credential": "PSYD",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2022-11-07",
"last_updated": "2024-08-09",
"certification_date": "2024-08-09",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "24992",
"primary": false
},
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "PSY24992",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Stockton, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 9, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.