Provider Demographics
NPI:1376851105
Name:PERSSON, KRISTIN M (PSYD)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:M
Last Name:PERSSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8312 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-9323
Mailing Address - Country:US
Mailing Address - Phone:619-855-2344
Mailing Address - Fax:619-741-0112
Practice Address - Street 1:8312 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-9323
Practice Address - Country:US
Practice Address - Phone:619-855-2344
Practice Address - Fax:619-741-0112
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23525103TA0700X, 103TB0200X, 103TC1900X, 103TF0000X, 103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily