Healthcare Provider Details

I. General information

NPI: 1386336501
Provider Name (Legal Business Name): BANYAN PSYCHOLOGY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 MAHLER RD STE 160
BURLINGAME CA
94010-1640
US

IV. Provider business mailing address

877 MAHLER RD STE 160
BURLINGAME CA
94010-1640
US

V. Phone/Fax

Practice location:
  • Phone: 650-822-1057
  • Fax: 650-563-5570
Mailing address:
  • Phone: 650-822-1057
  • Fax: 650-563-5570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM CHAN
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 650-667-7193