Provider Demographics
NPI:1265271597
Name:HOLDSTEIN, LYLA ROSE
Entity type:Individual
Prefix:
First Name:LYLA
Middle Name:ROSE
Last Name:HOLDSTEIN
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 1:200 LAKESIDE DR APT 503
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-5025
Mailing Address - Country:US
Mailing Address - Phone:415-999-0769
Mailing Address - Fax:
Practice Address - Street 1:2325 CLEMENT AVE STE A
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-7061
Practice Address - Country:US
Practice Address - Phone:510-629-6309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8121Medicaid