Provider Demographics
NPI:1548789779
Name:BLAINE, CORRINE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CORRINE
Middle Name:
Last Name:BLAINE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3186 AIRWAY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4650
Mailing Address - Country:US
Mailing Address - Phone:714-881-0427
Mailing Address - Fax:
Practice Address - Street 1:3186 AIRWAY AVE STE A
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4650
Practice Address - Country:US
Practice Address - Phone:714-881-0427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP28697235Z00000X
AZTSLP10755235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist