Healthcare Provider Details

I. General information

NPI: 1730423013
Provider Name (Legal Business Name): MS. POLINA KHERSONSKIY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3626 BALBOA ST
SAN FRANCISCO CA
94121-2604
US

IV. Provider business mailing address

3626 BALBOA ST
SAN FRANCISCO CA
94121-2604
US

V. Phone/Fax

Practice location:
  • Phone: 415-668-5955
  • Fax: 415-668-0246
Mailing address:
  • Phone: 415-668-5955
  • Fax: 415-668-0246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: