Provider Demographics
NPI:1932267366
Name:BLOESCH, STEPHANIE ANN (MFT)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ANN
Last Name:BLOESCH
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 1:171 CARLOS DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2005
Mailing Address - Country:US
Mailing Address - Phone:415-755-2310
Mailing Address - Fax:415-755-2210
Practice Address - Street 1:171 CARLOS DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2005
Practice Address - Country:US
Practice Address - Phone:415-755-2310
Practice Address - Fax:415-755-2210
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41505101YM0800X
CAMFC 41505101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2109OtherMEDI-CAL