Provider Demographics
NPI:1811097413
Name:KERSON, PATRICIA MOON
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:MOON
Last Name:KERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MOON
Other - Middle Name:
Other - Last Name:KERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:612 N SEPULVEDA BLVD STE 17
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-2180
Mailing Address - Country:US
Mailing Address - Phone:310-471-9997
Mailing Address - Fax:
Practice Address - Street 1:612 N SEPULVEDA BLVD STE 17
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-2180
Practice Address - Country:US
Practice Address - Phone:310-471-9997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11774103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical