Provider Demographics
NPI:1124109442
Name:KERCKHOFF, CARL MICHAEL (PHD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:MICHAEL
Last Name:KERCKHOFF
Suffix:
Gender:M
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 12371
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92859-8371
Mailing Address - Country:US
Mailing Address - Phone:949-412-8818
Mailing Address - Fax:
Practice Address - Street 1:670 N RICK ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-2663
Practice Address - Country:US
Practice Address - Phone:949-412-8818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 17976103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY17976OtherPSYCHOLOGIST LICENSE