1265639678 NPI number — DR. LISA ANN BLEVINS PHD

Table of content: DR. LISA ANN BLEVINS PHD (NPI 1265639678)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265639678 NPI number — DR. LISA ANN BLEVINS PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLEVINS
Provider First Name:
LISA
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265639678
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
484 E SAN FERNANDO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95112-3513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-794-7592
Provider Business Mailing Address Fax Number:
408-288-9824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 MISSION ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SANTA CRUZ
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95060-3661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-655-6219
Provider Business Practice Location Address Fax Number:
408-288-9824
Provider Enumeration Date:
06/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY 14707 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 030334 . This is a "SAN JOSE CITY EMPLOYEE ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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