Provider Demographics
NPI:1619116316
Name:HATTORI, BERYL (PHD)
Entity Type:Individual
Prefix:
First Name:BERYL
Middle Name:
Last Name:HATTORI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:BERYL
Other - Middle Name:
Other - Last Name:GAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3992
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-0992
Mailing Address - Country:US
Mailing Address - Phone:650-266-8209
Mailing Address - Fax:650-266-8209
Practice Address - Street 1:881 FREMONT AVE STE B8
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5637
Practice Address - Country:US
Practice Address - Phone:650-266-8209
Practice Address - Fax:650-266-8209
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22521103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical