Healthcare Provider Details

I. General information

NPI: 1063364164
Provider Name (Legal Business Name): GABRIEL ROSENBLOOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2026
Last Update Date: 06/07/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14860 ROSCOE BLVD STE 306
PANORAMA CITY CA
91402-7903
US

IV. Provider business mailing address

14860 ROSCOE BLVD STE 306
PANORAMA CITY CA
91402-7903
US

V. Phone/Fax

Practice location:
  • Phone: 818-616-2122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95038439
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: