Healthcare Provider Details

I. General information

NPI: 1932221520
Provider Name (Legal Business Name): PEGGY MULDER KERSULIS MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 ARTESIA BLVD SUITE A
MANHATTAN BEACH CA
90266-7158
US

IV. Provider business mailing address

243 CALLE DE MADRID
REDONDO BEACH CA
90277-6716
US

V. Phone/Fax

Practice location:
  • Phone: 310-791-5553
  • Fax: 310-791-5553
Mailing address:
  • Phone: 310-791-5553
  • Fax: 310-791-5553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC23007
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: