Provider Demographics
NPI:1558608489
Name:BLONIGEN, DANIEL MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MICHAEL
Last Name:BLONIGEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 MISSOURI ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-2837
Mailing Address - Country:US
Mailing Address - Phone:612-227-4123
Mailing Address - Fax:
Practice Address - Street 1:795 WILLOW RD
Practice Address - Street 2:MPD-152
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-2539
Practice Address - Country:US
Practice Address - Phone:650-493-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24592103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical