Provider Demographics
NPI:1114426525
Name:BLACKSHEAR, MARK G II
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:G
Last Name:BLACKSHEAR
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-1812
Mailing Address - Country:US
Mailing Address - Phone:619-273-4611
Mailing Address - Fax:
Practice Address - Street 1:3434 GROVE ST
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-1812
Practice Address - Country:US
Practice Address - Phone:619-281-3706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health