=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265271597
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYLA ROSE HOLDSTEIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2024
-----------------------------------------------------
Last Update Date | 05/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2325 CLEMENT AVE STE A
-----------------------------------------------------
City | ALAMEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94501-7061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-629-6309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 LAKESIDE DR APT 503
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94612-5025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-999-0769
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------