Healthcare Provider Details

I. General information

NPI: 1891978813
Provider Name (Legal Business Name): KRISTINE HIRAYAMA PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 12/02/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1963 N E ST
SAN BERNARDINO CA
92405-3919
US

IV. Provider business mailing address

1963 N E ST
SAN BERNARDINO CA
92405-3919
US

V. Phone/Fax

Practice location:
  • Phone: 909-881-6146
  • Fax: 909-881-0111
Mailing address:
  • Phone: 909-881-6146
  • Fax: 909-881-0111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY25892
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: