Healthcare Provider Details

I. General information

NPI: 1740164946
Provider Name (Legal Business Name): STEPHANIE BLANK AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2025
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 CLEMENT AVE
ALAMEDA CA
94501-7063
US

IV. Provider business mailing address

123 CLEMENT ST
SAN FRANCISCO CA
94118-2419
US

V. Phone/Fax

Practice location:
  • Phone: 510-629-6300
  • Fax:
Mailing address:
  • Phone: 267-496-3832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number150269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: