Provider Demographics
NPI:1265639678
Name:BLEVINS, LISA ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 E SAN FERNANDO ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-3513
Mailing Address - Country:US
Mailing Address - Phone:408-794-7592
Mailing Address - Fax:408-288-9824
Practice Address - Street 1:501 MISSION ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3661
Practice Address - Country:US
Practice Address - Phone:408-655-6219
Practice Address - Fax:408-288-9824
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 14707103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA030334OtherSAN JOSE CITY EMPLOYEE ID