Provider Demographics
NPI:1043808207
Name:BLAS, CONSUELO NEGRETE (AMFT)
Entity Type:Individual
Prefix:
First Name:CONSUELO
Middle Name:NEGRETE
Last Name:BLAS
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2070 N BROADWAY UNIT 4442
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-2018
Mailing Address - Country:US
Mailing Address - Phone:925-759-0560
Mailing Address - Fax:
Practice Address - Street 1:1320 ARNOLD DR STE 170
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-6537
Practice Address - Country:US
Practice Address - Phone:925-372-4213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT114746106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist