Provider Demographics
NPI:1003335936
Name:BLANK, YELENA (PHD)
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:
Other - Last Name:BLANK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:257 CASTRO ST STE 208
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94041-1287
Mailing Address - Country:US
Mailing Address - Phone:416-758-1335
Mailing Address - Fax:
Practice Address - Street 1:257 CASTRO ST STE 208
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94041-1287
Practice Address - Country:US
Practice Address - Phone:416-758-1335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28683103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical