Provider Demographics
NPI:1447899950
Name:KIRSON-TRILLING, ORTAL (PSYD)
Entity type:Individual
Prefix:
First Name:ORTAL
Middle Name:
Last Name:KIRSON-TRILLING
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 1:286 SANTA CLARA AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-2624
Mailing Address - Country:US
Mailing Address - Phone:510-496-2710
Mailing Address - Fax:
Practice Address - Street 1:286 SANTA CLARA AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-2624
Practice Address - Country:US
Practice Address - Phone:510-496-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17411103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist