Provider Demographics
NPI:1053442053
Name:BLANK, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31165 TEMECULA PKWY
Mailing Address - Street 2:SUITE G3 PMB 1035
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-2908
Mailing Address - Country:US
Mailing Address - Phone:626-404-4041
Mailing Address - Fax:951-595-7386
Practice Address - Street 1:31165 TEMECULA PKWY STE G3
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-2908
Practice Address - Country:US
Practice Address - Phone:626-404-4041
Practice Address - Fax:951-595-7386
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 390200000X
CALCSW804861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program