Provider Demographics
NPI:1760770192
Name:BLACKHURST, MARK DANIEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DANIEL
Last Name:BLACKHURST
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21633 AVENUE 24
Mailing Address - Street 2:
Mailing Address - City:CHOWCHILLA
Mailing Address - State:CA
Mailing Address - Zip Code:93610-9650
Mailing Address - Country:US
Mailing Address - Phone:559-665-6100
Mailing Address - Fax:
Practice Address - Street 1:21633 AVENUE 24
Practice Address - Street 2:
Practice Address - City:CHOWCHILLA
Practice Address - State:CA
Practice Address - Zip Code:93610-9650
Practice Address - Country:US
Practice Address - Phone:559-665-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28115103TC0700X
CA28115103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical