MEDICARE: DR. KEARNEY NICOLE VISSER PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	PSY23855	CA

General Provider Information

NPI Number	:	1265508824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEARNEY NICOLE VISSER PHD

Provider Business Mailing Address
First Line	:	12655 W WASHINGTON BLVD STE 208
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-2395
Country	:	US
Telephone Number	:	310-409-5463
Fax Number	:

Provider Business Practice Location Address
First Line	:	12655 W WASHINGTON BLVD STE 208
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-2395
Country	:	US
Telephone Number	:	310-409-5463
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2006
Last Update Date	:	03/03/2020

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