Provider Demographics
NPI:1164192282
Name:KERRIGAN, KELSEY OLIVER
Entity Type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:OLIVER
Last Name:KERRIGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4883 RONSON CT STE I
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-1812
Mailing Address - Country:US
Mailing Address - Phone:760-294-1206
Mailing Address - Fax:
Practice Address - Street 1:4883 RONSON CT STE I
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1812
Practice Address - Country:US
Practice Address - Phone:760-294-1206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-34354103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst