Provider Demographics
NPI:1649391848
Name:BLODGETT, LYNDON L (MFT)
Entity Type:Individual
Prefix:
First Name:LYNDON
Middle Name:L
Last Name:BLODGETT
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10428 RUBICON AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7113
Mailing Address - Country:US
Mailing Address - Phone:209-915-4748
Mailing Address - Fax:
Practice Address - Street 1:2431 W MARCH LN STE 200
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8211
Practice Address - Country:US
Practice Address - Phone:209-915-4748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 39810106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA-05-679Medicaid
CAMFT398100OtherBLUE SHIELD OF CALIFORNIA