Basic Information
| Provider Information | |||||||||
| NPI: | 1326175878 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KREMSDORF | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | BRYAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD, JD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 651 HUNTINGTON RD | ||||||||
| Address2: | |||||||||
| City: | CAMBRIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934283607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6614265263 | ||||||||
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| Practice Location | |||||||||
| Address1: | 676 PISMO ST | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934013945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055437969 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 12/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY 6271 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.