Basic Information
| Provider Information | |||||||||
| NPI: | 1508972753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIETZMAN | ||||||||
| FirstName: | ROBIN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 447 N EL MOLINO AVE. | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265778480 | ||||||||
| FaxNumber: | 6265778978 | ||||||||
| Practice Location | |||||||||
| Address1: | 447 N EL MOLINO AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265778480 | ||||||||
| FaxNumber: | 6265778978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 05/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 103TC0700X | PSY21015 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.