=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861421463
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN CAROL ROSENBLUTH PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 930 N DOHENY DR #307
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-3172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-888-8749
-----------------------------------------------------
Fax | 310-388-5238
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 930 N DOHENY DR #307
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-3172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-888-8749
-----------------------------------------------------
Fax | 310-388-5238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY 20139
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 011986
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------