Healthcare Provider Details

I. General information

NPI: 1740292689
Provider Name (Legal Business Name): BRIAN CHRISTOPHER KERSH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE BHCL (116)
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

12 FOREST RD
TIJERAS NM
87059-7447
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-256-5438
Mailing address:
  • Phone: 505-286-7702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number0895
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: