Provider Demographics
NPI:1033426101
Name:BLODGETT, ROBYN CHERISE
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:CHERISE
Last Name:BLODGETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROBYN
Other - Middle Name:CHERISE
Other - Last Name:FRAZIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 S PROCTOR ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2047
Mailing Address - Country:US
Mailing Address - Phone:253-396-5800
Mailing Address - Fax:253-566-2252
Practice Address - Street 1:815 S PEARL ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-2117
Practice Address - Country:US
Practice Address - Phone:253-396-5930
Practice Address - Fax:253-566-2252
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60155259101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60155259OtherCOUNSELOR AGENCY AFFILIATEE REGISTRATION