Provider Demographics
NPI:1932221520
Name:KERSULIS, PEGGY MULDER (MFT)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:MULDER
Last Name:KERSULIS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 CALLE DE MADRID
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-6716
Mailing Address - Country:US
Mailing Address - Phone:310-791-5553
Mailing Address - Fax:310-791-5553
Practice Address - Street 1:1721 ARTESIA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-7158
Practice Address - Country:US
Practice Address - Phone:310-791-5553
Practice Address - Fax:310-791-5553
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC23007106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist