Provider Demographics
NPI:1487030862
Name:CRAWFORD, BLAKE ELDON
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:ELDON
Last Name:CRAWFORD
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 1:27261 LAS RAMBLAS STE 220
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6468
Mailing Address - Country:US
Mailing Address - Phone:877-527-7227
Mailing Address - Fax:
Practice Address - Street 1:1425 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-8007
Practice Address - Country:US
Practice Address - Phone:909-980-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-07
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT86176106H00000X
CAAMFT125194106H00000X
CA136036106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist