Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) |
NPI | 1003093394 |
---|---|
Provider Name | Geoff Blaylock |
First Address | Santa Ana, CA 92706-2334 |
Second Address | Santa Ana, CA 92706-2334 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2008 |
Last Update Date | 29/01/2008 |