Healthcare Provider Details

I. General information

NPI: 1437692621
Provider Name (Legal Business Name): KERSEY PETERSON CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2016
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9089 CLAIREMONT MESA BLVD SUITE 200
SAN DIEGO CA
92123-1234
US

IV. Provider business mailing address

9089 CLAIREMONT MESA BLVD SUITE 200
SAN DIEGO CA
92123-1234
US

V. Phone/Fax

Practice location:
  • Phone: 800-787-6787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: