1871801803 NPI number — MRS. CARLY SANTOS BLALACK LCSW, PPS

Table of content: MRS. CARLY SANTOS BLALACK LCSW, PPS (NPI 1871801803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871801803 NPI number — MRS. CARLY SANTOS BLALACK LCSW, PPS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLALACK
Provider First Name:
CARLY
Provider Middle Name:
SANTOS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW, PPS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SANTOS
Provider Other First Name:
CARLY
Provider Other Middle Name:
ELISABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1871801803
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3835 N FREEWAY BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95834-1954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-576-7900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 SPRING ST STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-0274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-667-3380
Provider Business Practice Location Address Fax Number:
619-667-0815
Provider Enumeration Date:
09/24/2010

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: 1041C0700X , with the licence number:  29364 , 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)





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