Provider Demographics
NPI:1689750051
Name:BLATT, BERNICE R (LCSW)
Entity Type:Individual
Prefix:MS
First Name:BERNICE
Middle Name:R
Last Name:BLATT
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 1:16055 VENTURA BLVD
Mailing Address - Street 2:SUITE 1220
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2601
Mailing Address - Country:US
Mailing Address - Phone:818-906-8311
Mailing Address - Fax:
Practice Address - Street 1:16055 VENTURA BLVD
Practice Address - Street 2:SUITE 1220
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2601
Practice Address - Country:US
Practice Address - Phone:818-906-8311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS111501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW11150Medicare PIN