Provider Demographics
NPI:1487299764
Name:SHEEPER, KYRA NICOLE
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:NICOLE
Last Name:SHEEPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 PACIFIC HWY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-2030
Mailing Address - Country:US
Mailing Address - Phone:619-393-2000
Mailing Address - Fax:
Practice Address - Street 1:4141 PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2030
Practice Address - Country:US
Practice Address - Phone:619-393-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-11
Last Update Date:2022-11-07
Deactivation Date:2022-10-19
Deactivation Code:
Reactivation Date:2022-11-04
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician