Basic Information
| Provider Information | |||||||||
| NPI: | 1790445781 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASATSUGU | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | MIKA | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12161 9TH ST | ||||||||
| Address2: | |||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928403532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109102005 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1514 VALLEY VISTA DR | ||||||||
| Address2: | |||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917653929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098601144 | ||||||||
| FaxNumber: | 9098608307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2021 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 81092 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.