Provider Demographics
NPI:1659527695
Name:BLAKE, PARISSA
Entity Type:Individual
Prefix:
First Name:PARISSA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4570 CAMPUS DR
Mailing Address - Street 2:#5
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8809
Mailing Address - Country:US
Mailing Address - Phone:714-215-6374
Mailing Address - Fax:
Practice Address - Street 1:4570 CAMPUS DR
Practice Address - Street 2:#5
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8809
Practice Address - Country:US
Practice Address - Phone:714-215-6374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-11
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37195106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist