Provider Demographics
NPI:1114440021
Name:BLEVINS, LORETTA S
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:S
Last Name:BLEVINS
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 1:1809 BALLINA DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-1318
Mailing Address - Country:US
Mailing Address - Phone:619-727-1549
Mailing Address - Fax:
Practice Address - Street 1:321 CASSIDY ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5314
Practice Address - Country:US
Practice Address - Phone:760-721-2171
Practice Address - Fax:760-721-8582
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4414101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor