Provider Demographics
NPI:1184871949
Name:KLEIN, MAYA BRISTOW (PHD)
Entity type:Individual
Prefix:DR
First Name:MAYA
Middle Name:BRISTOW
Last Name:KLEIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11403 W BERNARDO CT # 205
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1639
Mailing Address - Country:US
Mailing Address - Phone:760-846-8852
Mailing Address - Fax:
Practice Address - Street 1:10260 SW GREENBURG RD STE 400
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5514
Practice Address - Country:US
Practice Address - Phone:503-244-7674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-24
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2901103T00000X
CAPSY26592103T00000X, 103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB221132Medicare UPIN