Provider Demographics
NPI:1104956556
Name:BERENSON, LAURIE ELLEN (PSYD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ELLEN
Last Name:BERENSON
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 1:450 S MELROSE DR STE 113
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6674
Mailing Address - Country:US
Mailing Address - Phone:760-224-4333
Mailing Address - Fax:760-301-0044
Practice Address - Street 1:450 S MELROSE DR STE 113
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-6674
Practice Address - Country:US
Practice Address - Phone:760-224-4333
Practice Address - Fax:760-301-0044
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12568103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical