Provider Demographics
NPI:1790954600
Name:BLITZ, BAMBI L (MASTERS DEGREE)
Entity Type:Individual
Prefix:MS
First Name:BAMBI
Middle Name:L
Last Name:BLITZ
Suffix:
Gender:F
Credentials:MASTERS DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14016 BORA BORA WAY
Mailing Address - Street 2:#238
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6889
Mailing Address - Country:US
Mailing Address - Phone:213-488-9559
Mailing Address - Fax:
Practice Address - Street 1:527 CROCKER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-2116
Practice Address - Country:US
Practice Address - Phone:213-488-9559
Practice Address - Fax:213-683-0969
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23023106H00000X
CA56437106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist