Healthcare Provider Details

I. General information

NPI: 1376851105
Provider Name (Legal Business Name): KRISTIN M PERSSON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8312 UNIVERSITY AVE
LA MESA CA
91942-9323
US

IV. Provider business mailing address

8312 UNIVERSITY AVE
LA MESA CA
91942-9323
US

V. Phone/Fax

Practice location:
  • Phone: 619-855-2344
  • Fax: 619-741-0112
Mailing address:
  • Phone: 619-855-2344
  • Fax: 619-741-0112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY23525
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY23525
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY23525
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY23525
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY23525
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: