Provider Demographics
NPI:1992521678
Name:BLACKSTON, BATHSHEVA (MFT-INTERN)
Entity type:Individual
Prefix:
First Name:BATHSHEVA
Middle Name:
Last Name:BLACKSTON
Suffix:
Gender:F
Credentials:MFT-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5051 N 37TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2242
Mailing Address - Country:US
Mailing Address - Phone:213-709-7001
Mailing Address - Fax:
Practice Address - Street 1:2419 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-6605
Practice Address - Country:US
Practice Address - Phone:954-361-4535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT4162106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist