Provider Demographics
NPI:1770218067
Name:ROSENBLATT, STEPHEN MARK
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARK
Last Name:ROSENBLATT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 GATEWAY DR APT 5517
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5063
Mailing Address - Country:US
Mailing Address - Phone:571-668-0732
Mailing Address - Fax:
Practice Address - Street 1:4060 GATEWAY DR APT 5517
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5063
Practice Address - Country:US
Practice Address - Phone:571-668-0732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2023-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0903003905104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker