Provider Demographics
NPI:1962924514
Name:GOLDBLATT, ILYSA SHARI (PSYD)
Entity type:Individual
Prefix:DR
First Name:ILYSA
Middle Name:SHARI
Last Name:GOLDBLATT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2268 CAMINO RAMON
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1353
Mailing Address - Country:US
Mailing Address - Phone:415-518-6202
Mailing Address - Fax:
Practice Address - Street 1:3569 SACRAMENTO ST # 310
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1866
Practice Address - Country:US
Practice Address - Phone:415-518-6202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29101103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty