Provider Demographics
NPI:1679624415
Name:BLATNICK, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:BLATNICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-3430
Mailing Address - Country:US
Mailing Address - Phone:707-951-5055
Mailing Address - Fax:707-458-3014
Practice Address - Street 1:422 9TH ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-3430
Practice Address - Country:US
Practice Address - Phone:707-951-5055
Practice Address - Fax:707-458-3014
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 18745106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist