Provider Demographics
NPI:1558394619
Name:BLUNDEN, DALE LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:LYNN
Last Name:BLUNDEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5904
Mailing Address - Country:US
Mailing Address - Phone:916-448-8481
Mailing Address - Fax:
Practice Address - Street 1:2617 CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5904
Practice Address - Country:US
Practice Address - Phone:916-448-8481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10044103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL100441Medicare ID - Type Unspecified