Provider Demographics
NPI:1730193822
Name:MAISEL, RICHARD LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LYNN
Last Name:MAISEL
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 1:1530 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94710-1713
Mailing Address - Country:US
Mailing Address - Phone:510-526-2710
Mailing Address - Fax:510-525-2102
Practice Address - Street 1:1530 5TH ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94710-1713
Practice Address - Country:US
Practice Address - Phone:510-526-2710
Practice Address - Fax:510-525-2102
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13594103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3941142Medicaid
CAOPL135940Medicare ID - Type Unspecified