Provider Demographics
NPI:1629492566
Name:BLATT, SHYLAH ABBIE
Entity Type:Individual
Prefix:
First Name:SHYLAH
Middle Name:ABBIE
Last Name:BLATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CHARLES LN
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-2511
Mailing Address - Country:US
Mailing Address - Phone:925-240-3793
Mailing Address - Fax:
Practice Address - Street 1:3180 CROW CANYON PL STE 140
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1339
Practice Address - Country:US
Practice Address - Phone:925-240-3793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76030101YM0800X
CA94803106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health