Provider Demographics
NPI:1518252071
Name:ALCOTT, KERRY LYN
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:LYN
Last Name:ALCOTT
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 1:5133 COSTA RUSTICO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-7120
Mailing Address - Country:US
Mailing Address - Phone:949-246-1888
Mailing Address - Fax:
Practice Address - Street 1:2721 E COAST HWY STE 209
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2131
Practice Address - Country:US
Practice Address - Phone:949-246-1888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC35608106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist