Provider Demographics
NPI:1700110038
Name:BARR, REVITAL (PHD)
Entity Type:Individual
Prefix:
First Name:REVITAL
Middle Name:
Last Name:BARR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TALI
Other - Middle Name:
Other - Last Name:BARR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:454 VASSAR AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94708-1216
Mailing Address - Country:US
Mailing Address - Phone:510-433-2800
Mailing Address - Fax:
Practice Address - Street 1:454 VASSAR AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94708-1216
Practice Address - Country:US
Practice Address - Phone:510-433-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-18
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17466103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist