Provider Demographics
NPI:1649560988
Name:ROTHBLATT, PHYLLIS C (MFT)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:C
Last Name:ROTHBLATT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4287 PIEDMONT AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-4730
Mailing Address - Country:US
Mailing Address - Phone:510-325-3077
Mailing Address - Fax:
Practice Address - Street 1:3301 E 12TH ST
Practice Address - Street 2:SUITE 259
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3424
Practice Address - Country:US
Practice Address - Phone:510-325-3077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30233106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist