Provider Demographics
NPI:1114060282
Name:KILPATRICK-TABAK, BLAIR (PHD)
Entity Type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:
Last Name:KILPATRICK-TABAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:BLAIR
Other - Middle Name:
Other - Last Name:KILPATRICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1507 ADA ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1001
Mailing Address - Country:US
Mailing Address - Phone:510-526-4848
Mailing Address - Fax:
Practice Address - Street 1:3100 MOWRY AVE
Practice Address - Street 2:STE 410
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1509
Practice Address - Country:US
Practice Address - Phone:510-791-1036
Practice Address - Fax:510-791-1036
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15604103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical