Provider Demographics
NPI:1336658574
Name:BLAUNER, DAVID KOVI
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:KOVI
Last Name:BLAUNER
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 1:13100 ALBERS ST
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-6002
Mailing Address - Country:US
Mailing Address - Phone:323-841-3717
Mailing Address - Fax:
Practice Address - Street 1:5675 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4712
Practice Address - Country:US
Practice Address - Phone:323-965-1365
Practice Address - Fax:323-965-0444
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1265790917101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)