Active NPI
Kelley Grace Herskovic, MRS.
- Occupational Therapist
- Santa Rosa, CA
National Provider Identifier
1154864403
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Occupational Therapist
- License
- 11709
- Practice address
- 1165 Montgomery Dr
Santa Rosa, CA 95405 - Phone
- (707) 637-3276
- NPI assigned
- Nov 18, 2016
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapist | 225X00000X | 11709 | CA | Primary |
Addresses
Primary practice location
1165 Montgomery Dr
Santa Rosa, CA 95405
Mailing address
324 Maria Dr
Petaluma, CA 94954
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11709 | CA | MD | Acute Care Nurse Practitioner |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1479427200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1479427200000",
"number": "1154864403",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "324 MARIA DR",
"city": "PETALUMA",
"state": "CA",
"postal_code": "94954"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1165 MONTGOMERY DR",
"city": "SANTA ROSA",
"state": "CA",
"postal_code": "95405",
"telephone_number": "707-637-3276"
}
],
"practiceLocations": [],
"basic": {
"last_name": "HERSKOVIC",
"first_name": "KELLEY",
"middle_name": "GRACE",
"credential": "MRS.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2016-11-18",
"last_updated": "2016-11-18",
"status": "A"
},
"taxonomies": [
{
"code": "225X00000X",
"taxonomy_group": "",
"desc": "Occupational Therapist",
"state": "CA",
"license": "11709",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Santa Rosa, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 18, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.