Provider Demographics
NPI:1467522243
Name:BLAS, VIVIAN (MFT 17709MFT)
Entity Type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:
Last Name:BLAS
Suffix:
Gender:F
Credentials:MFT 17709MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 RIVERSIDE DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504
Mailing Address - Country:US
Mailing Address - Phone:818-845-0366
Mailing Address - Fax:818-972-9033
Practice Address - Street 1:4405 RIVERSIDE DR
Practice Address - Street 2:SUITE 106
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504
Practice Address - Country:US
Practice Address - Phone:818-845-0366
Practice Address - Fax:818-972-9033
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17709MFT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17709OtherMFT