Provider Demographics
NPI:1467825125
Name:HERZBERG PURDY, KRISTIN NICOLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:NICOLE
Last Name:HERZBERG PURDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KRISTIN
Other - Middle Name:NICOLE
Other - Last Name:HERZBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:5480 BALTIMORE DR
Mailing Address - Street 2:#250
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2020
Mailing Address - Country:US
Mailing Address - Phone:310-863-0767
Mailing Address - Fax:
Practice Address - Street 1:5480 BALTIMORE DR
Practice Address - Street 2:#250
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2020
Practice Address - Country:US
Practice Address - Phone:310-863-0767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27449103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist