Provider Demographics
NPI:1659061216
Name:BLENKO, KATHLEEN MARY
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARY
Last Name:BLENKO
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:MARY
Other - Last Name:KEHRL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT
Mailing Address - Street 1:32210 HELM PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-6016
Mailing Address - Country:US
Mailing Address - Phone:310-377-6515
Mailing Address - Fax:
Practice Address - Street 1:32210 HELM PL
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-6016
Practice Address - Country:US
Practice Address - Phone:310-377-6515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA121815106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist