Provider Demographics
NPI:1215144902
Name:ROSENBLUM, PHILLIP LEON (MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:LEON
Last Name:ROSENBLUM
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6412 GOLDEN EYE GLN
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-5834
Mailing Address - Country:US
Mailing Address - Phone:941-536-0671
Mailing Address - Fax:
Practice Address - Street 1:1495 CHAIN BRIDGE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-5727
Practice Address - Country:US
Practice Address - Phone:703-517-0435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040001011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6161-0001OtherCAREFIRST BC-BS