Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | PSY15196 | CA |
N | 103T00000X | Psychologist | PSY15196 | CA |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | PSY15196 | CA |
NPI | 1134230303 |
---|---|
Provider Name | Dr. Susan Trese Bernadett |
First Address | Los Altos, CA 94022-2345 |
Second Address | Los Altos, CA 94022-1069 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 08/07/2007 |