Provider Demographics
NPI:1134230303
Name:BERNADETT, SUSAN TRESE (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:TRESE
Last Name:BERNADETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:TRESE
Other - Last Name:BERNADETT-SHAPIRO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:385 VERANO DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-2345
Mailing Address - Country:US
Mailing Address - Phone:650-948-7292
Mailing Address - Fax:650-948-1464
Practice Address - Street 1:4546 EL CAMINO REAL STE 242
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-1069
Practice Address - Country:US
Practice Address - Phone:650-948-7292
Practice Address - Fax:650-948-1464
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15196103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist