Provider Demographics
NPI:1891558433
Name:LIVE OAK PSYCHOLOGICAL SERVICES, PC
Entity Type:Organization
Organization Name:LIVE OAK PSYCHOLOGICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:510-214-2110
Mailing Address - Street 1:107 TAMALPAIS RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94708-1948
Mailing Address - Country:US
Mailing Address - Phone:510-872-6631
Mailing Address - Fax:
Practice Address - Street 1:2020 MILVIA ST STE 450
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1297
Practice Address - Country:US
Practice Address - Phone:510-214-2110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1326523044OtherNPPES