Provider Demographics
NPI:1265508824
Name:VISSER, KEARNEY NICOLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEARNEY
Middle Name:NICOLE
Last Name:VISSER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12655 W WASHINGTON BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-2395
Mailing Address - Country:US
Mailing Address - Phone:310-409-5463
Mailing Address - Fax:
Practice Address - Street 1:12655 W WASHINGTON BLVD STE 208
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-2395
Practice Address - Country:US
Practice Address - Phone:310-409-5463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23855103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent