Provider Demographics
NPI:1942588181
Name:ORMISTON, ANNICE (PSYD)
Entity Type:Individual
Prefix:
First Name:ANNICE
Middle Name:
Last Name:ORMISTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 HEARST AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-2260
Mailing Address - Country:US
Mailing Address - Phone:510-852-9322
Mailing Address - Fax:888-972-2231
Practice Address - Street 1:2000 HEARST AVE STE 207
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-2260
Practice Address - Country:US
Practice Address - Phone:510-852-9322
Practice Address - Fax:888-972-2231
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25092103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA158903Medicare PIN
CAGI662AMedicare PIN