Provider Demographics
NPI:1841386885
Name:KISSELOVICH, TERRI LYNNE (LCSW)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNNE
Last Name:KISSELOVICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 MORENA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3815
Mailing Address - Country:US
Mailing Address - Phone:619-692-8750
Mailing Address - Fax:619-275-7343
Practice Address - Street 1:1250 MORENA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3815
Practice Address - Country:US
Practice Address - Phone:619-692-8750
Practice Address - Fax:619-275-7343
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW276731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical