Provider Demographics
NPI:1285654681
Name:BLASE, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BLASE
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 1:201 BRYANT ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OJAI
Mailing Address - State:CA
Mailing Address - Zip Code:93023-5003
Mailing Address - Country:US
Mailing Address - Phone:805-646-0073
Mailing Address - Fax:805-646-0073
Practice Address - Street 1:201 BRYANT ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OJAI
Practice Address - State:CA
Practice Address - Zip Code:93023-5003
Practice Address - Country:US
Practice Address - Phone:805-646-0073
Practice Address - Fax:805-646-0073
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC28272106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC28272OtherLICENSE