MEDICARE: KELSHA PERINE

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	106S00000X	Behavior Technician	18-66499

General Provider Information

NPI Number	:	1821567967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSHA PERINE

Provider Business Mailing Address
First Line	:	13488 MAXELLA AVE APT 569
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-4305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13488 MAXELLA AVE APT 569
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-4305
Country	:	US
Telephone Number	:	323-208-1551
Fax Number	:

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

Provider Enumeration Date	:	11/19/2018
Last Update Date	:	11/19/2018

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Directions to “ KELSHA PERINE ” Practice Location

Language	Start Address	Practice Location

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