Provider Demographics
NPI:1235689910
Name:BLOMMER, BELISSA
Entity Type:Individual
Prefix:
First Name:BELISSA
Middle Name:
Last Name:BLOMMER
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 1:1501 HUGHES WAY STE 150
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90810-1878
Mailing Address - Country:US
Mailing Address - Phone:310-221-6336
Mailing Address - Fax:
Practice Address - Street 1:1501 HUGHES WAY STE 150
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810-1878
Practice Address - Country:US
Practice Address - Phone:310-221-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC44943106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist