1780620906 NPI number — KERRI N. BOUTELLE PHD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780620906 NPI number — KERRI N. BOUTELLE PHD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BOUTELLE

Provider First Name:

KERRI

Provider Middle Name:

N.

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

PHD

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1780620906

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/22/2019

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 232410

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SAN DIEGO

Provider Business Mailing Address State Name:

CA

Provider Business Mailing Address Postal Code:

92193-2410

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

858-249-6748

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

9500 GILMAN DRIVE MC 0985

Provider Second Line Business Practice Location Address:

UNIVERSITY OF CALIFORNIA SAN DIEGO

Provider Business Practice Location Address City Name:

LA JOLLA

Provider Business Practice Location Address State Name:

CA

Provider Business Practice Location Address Postal Code:

92093

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

858-534-8037

Provider Business Practice Location Address Fax Number:

858-534-6727

Provider Enumeration Date:

06/22/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 103TC0700X , with the licence number:  PSY21823 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 103TC2200X , with the licence number: PSY21823 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 123420 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 205A4BO . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 923517500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 10387 . This is a "ND MA" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
• Identifier: 61-60634 . This is a "MEDICA CHOICE & PRIMARY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 839397 . This is a "ARAZ" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 7777470 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
• Identifier: 0491997 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
• Identifier: 1019785 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 39136900 . This is a "WI MA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
• Identifier: HP34903 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".