Provider Demographics
NPI:1275821514
Name:KERRY L. GARRETSON, PH.D.
Entity Type:Organization
Organization Name:KERRY L. GARRETSON, PH.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRETSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:419-866-4644
Mailing Address - Street 1:4986 COUNTY ROAD 6 1
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:OH
Mailing Address - Zip Code:43515-9241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6912 SPRING VALLEY DR
Practice Address - Street 2:SUITE 202C
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-9676
Practice Address - Country:US
Practice Address - Phone:419-866-4644
Practice Address - Fax:419-861-5040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0528003Medicaid