Provider Demographics
NPI:1689652828
Name:PEARLE, PHYLLIS R (MS, CGC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:R
Last Name:PEARLE
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4367 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1315
Mailing Address - Country:US
Mailing Address - Phone:510-919-2451
Mailing Address - Fax:
Practice Address - Street 1:5730 TELEGRAPH AVE STE 117
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1710
Practice Address - Country:US
Practice Address - Phone:510-570-3515
Practice Address - Fax:415-369-1391
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
170300000X
CAGC000103170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170300000XOther Service ProvidersGenetic Counselor, MSGroup - Single Specialty