Provider Demographics
NPI:1366574139
Name:GERSTEIN, LOREN (PHD)
Entity type:Individual
Prefix:DR
First Name:LOREN
Middle Name:
Last Name:GERSTEIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4202
Mailing Address - Country:US
Mailing Address - Phone:707-706-3288
Mailing Address - Fax:707-576-7875
Practice Address - Street 1:633 CHERRY ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4202
Practice Address - Country:US
Practice Address - Phone:707-706-3288
Practice Address - Fax:707-576-7875
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15737103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11701062OtherCAQH
CA0PL157371Medicare UPIN