Provider Demographics
NPI:1134502834
Name:EBERLY, KRISTEN (MSW)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:EBERLY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:ESTREM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3020 CHILDRENS WAY # MC-5016
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-576-1700
Mailing Address - Fax:
Practice Address - Street 1:3665 KEARNY VILLA RD
Practice Address - Street 2:SUITE 501
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-576-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALCSW826251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health