Provider Demographics
NPI:1467821199
Name:BLANK, EMELIE ANGELINA (MA)
Entity Type:Individual
Prefix:MS
First Name:EMELIE
Middle Name:ANGELINA
Last Name:BLANK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:EMILY
Other - Last Name:GAGLIARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6012 N VILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-4039
Mailing Address - Country:US
Mailing Address - Phone:971-319-4827
Mailing Address - Fax:503-662-6221
Practice Address - Street 1:7319 N JOHN AVE STE 101
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-4890
Practice Address - Country:US
Practice Address - Phone:971-319-4827
Practice Address - Fax:503-662-6221
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5035101Y00000X
WAGAGLIRE118MG390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program