Provider Demographics
NPI:1053618314
Name:ELIZABETH LEE ROSENBLATT, PSYD, A PSYCHOLOGICAL CORPORATION
Entity type:Organization
Organization Name:ELIZABETH LEE ROSENBLATT, PSYD, A PSYCHOLOGICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROSENBLATT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:310-502-1162
Mailing Address - Street 1:12405 VENICE BLVD
Mailing Address - Street 2:124
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3803
Mailing Address - Country:US
Mailing Address - Phone:310-502-1162
Mailing Address - Fax:866-485-1162
Practice Address - Street 1:12405 VENICE BLVD
Practice Address - Street 2:124
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3803
Practice Address - Country:US
Practice Address - Phone:310-502-1162
Practice Address - Fax:866-485-1162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21110103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty