Provider Demographics
NPI:1447459219
Name:SYREN-VITULLO, DEBORAH ANN (PHD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ANN
Last Name:SYREN-VITULLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:ANN
Other - Last Name:VITULLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:5905 SOQUEL DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-2855
Mailing Address - Country:US
Mailing Address - Phone:831-332-3555
Mailing Address - Fax:
Practice Address - Street 1:5905 SOQUEL DR
Practice Address - Street 2:SUITE 600
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2855
Practice Address - Country:US
Practice Address - Phone:831-332-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14934103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY14934OtherBOARD OF PSYCHOLOGY