Healthcare Provider Details

I. General information

NPI: 1487299764
Provider Name (Legal Business Name): KYRA NICOLE SHEEPER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date: 10/19/2022
Reactivation Date: 11/04/2022

III. Provider practice location address

4141 PACIFIC HWY
SAN DIEGO CA
92110-2030
US

IV. Provider business mailing address

4141 PACIFIC HWY
SAN DIEGO CA
92110-2030
US

V. Phone/Fax

Practice location:
  • Phone: 619-393-2000
  • Fax:
Mailing address:
  • Phone: 619-393-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: