Healthcare Provider Details

I. General information

NPI: 1285941682
Provider Name (Legal Business Name): SEQUOIA KERMOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11622 EL CAMINO REAL STE 100
SAN DIEGO CA
92130-2051
US

IV. Provider business mailing address

PO BOX 963
CHULA VISTA CA
91912-0963
US

V. Phone/Fax

Practice location:
  • Phone: 858-314-8240
  • Fax:
Mailing address:
  • Phone: 858-432-9744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSB94023983
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: