Provider Demographics
NPI:1487632980
Name:BLOUNT, TALISA (MA)
Entity Type:Individual
Prefix:
First Name:TALISA
Middle Name:
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9371 ALDERBURY ST
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-2806
Mailing Address - Country:US
Mailing Address - Phone:714-995-2128
Mailing Address - Fax:
Practice Address - Street 1:1301 W PROVIDENCE AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3808
Practice Address - Country:US
Practice Address - Phone:714-639-4990
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU2153231H00000X
CAHA4112231HA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0021530Medicaid