Provider Demographics
NPI:1992554620
Name:CEZARIO, KERI DENISE (RADT1)
Entity type:Individual
Prefix:MRS
First Name:KERI
Middle Name:DENISE
Last Name:CEZARIO
Suffix:
Gender:F
Credentials:RADT1
Other - Prefix:MRS
Other - First Name:KERI
Other - Middle Name:DENISE
Other - Last Name:CLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1831 KELLI WAY
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-3279
Mailing Address - Country:US
Mailing Address - Phone:707-223-3450
Mailing Address - Fax:
Practice Address - Street 1:733 CEDAR ST
Practice Address - Street 2:
Practice Address - City:GARBERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95542-3201
Practice Address - Country:US
Practice Address - Phone:707-923-2931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1534321023101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)