Provider Demographics
NPI:1326256652
Name:BLANTERN, GEORGE LEONARD
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:LEONARD
Last Name:BLANTERN
Suffix:
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 1:9465 OVIEDO ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-3806
Mailing Address - Country:US
Mailing Address - Phone:858-484-3759
Mailing Address - Fax:
Practice Address - Street 1:13004 BRIXTON PL
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-1325
Practice Address - Country:US
Practice Address - Phone:858-484-3759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC22072106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist