Provider Demographics
NPI:1477699874
Name:RATTELY, PHYLLIS ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:ANN
Last Name:RATTELY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22314 MOJAVE RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:CEDARPINES PARK
Mailing Address - State:CA
Mailing Address - Zip Code:92522
Mailing Address - Country:US
Mailing Address - Phone:909-338-4600
Mailing Address - Fax:909-338-4600
Practice Address - Street 1:700 E GILBERT ST
Practice Address - Street 2:COTTAGE 4 ACCESS
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-1003
Practice Address - Country:US
Practice Address - Phone:909-386-0763
Practice Address - Fax:909-386-0770
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS141761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ25559ZMedicare ID - Type UnspecifiedLCSW