Provider Demographics
NPI:1780620906
Name:BOUTELLE, KERRI N (PHD)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:N
Last Name:BOUTELLE
Suffix:
Gender:F
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:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:858-249-6748
Mailing Address - Fax:
Practice Address - Street 1:9500 GILMAN DRIVE MC 0985
Practice Address - Street 2:UNIVERSITY OF CALIFORNIA SAN DIEGO
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093
Practice Address - Country:US
Practice Address - Phone:858-534-8037
Practice Address - Fax:858-534-6727
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21823103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN123420OtherUCARE
MN205A4BOOtherBCBS
MN923517500Medicaid
ND10387OtherND MA
MN61-60634OtherMEDICA CHOICE & PRIMARY
MN839397OtherARAZ
SD7777470Medicaid
MT0491997Medicaid
MN1019785OtherPREFERRED ONE
WI39136900OtherWI MA
MNHP34903OtherHEALTHPARTNERS