Provider Demographics
NPI:1609433101
Name:KRISTIN BLANEY, INDIVIDUAL & FAMILY THERAPY, INC.
Entity Type:Organization
Organization Name:KRISTIN BLANEY, INDIVIDUAL & FAMILY THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:JOANNA
Authorized Official - Last Name:BLANEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:949-633-6516
Mailing Address - Street 1:5215 VISTA DE OLMO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-7114
Mailing Address - Country:US
Mailing Address - Phone:949-633-6516
Mailing Address - Fax:
Practice Address - Street 1:161 AVENIDA CABRILLO
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4040
Practice Address - Country:US
Practice Address - Phone:949-633-6516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-21
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1285092791Medicaid