Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | LCSW80486 | CA |
N | 225400000X | Rehabilitation Practitioner |
NPI | 1053442053 |
---|---|
Provider Name | Emily Blank |
First Address | Temecula, CA 92592-2908 |
Second Address | Temecula, CA 92592-2908 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/03/2007 |
Last Update Date | 22/04/2021 |