Provider Demographics
NPI:1255472452
Name:ROSENBERG, GRAHAM D (MFT)
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:D
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15750 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1012
Mailing Address - Country:US
Mailing Address - Phone:510-667-4901
Mailing Address - Fax:
Practice Address - Street 1:15750 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1012
Practice Address - Country:US
Practice Address - Phone:510-667-4901
Practice Address - Fax:510-667-4964
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMFT #138101YM0800X
CAMFC 41511101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health