Healthcare Provider Details

I. General information

NPI: 1780620906
Provider Name (Legal Business Name): KERRI N. BOUTELLE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 GILMAN DRIVE MC 0985 UNIVERSITY OF CALIFORNIA SAN DIEGO
LA JOLLA CA
92093
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 858-534-8037
  • Fax: 858-534-6727
Mailing address:
  • Phone: 858-249-6748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21823
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY21823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: