Provider Demographics
NPI:1891839452
Name:GARRETSON, KERRY LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:LEE
Last Name:GARRETSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4986 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
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2500103T00000X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0528003Medicaid