Healthcare Provider Details

I. General information

NPI: 1265508824
Provider Name (Legal Business Name): KEARNEY NICOLE VISSER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12655 W WASHINGTON BLVD STE 208
LOS ANGELES CA
90066-2395
US

IV. Provider business mailing address

12655 W WASHINGTON BLVD STE 208
LOS ANGELES CA
90066-2395
US

V. Phone/Fax

Practice location:
  • Phone: 310-409-5463
  • Fax:
Mailing address:
  • Phone: 310-409-5463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY23855
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: